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Full text of "U.S. Navy Magazine Volume 68, Number 4 April 1977"

VADM Willan, P. Arentzen, MC, USN 

Surgeon General of the Navy 

RADM Paul Kaufinan, MC, USN 

Deputy Surgeon General 

EDITOR 

Sylvia W. Shaffer 

MANAGING EDITOR 

June Wyman 

ASSISTANT EDITOR 

Virginia M. Novinski 

EDITORIAL ASSISTANT 

Nancy R. Keesee 

CONTRIBUTING EDITORS 

Contributing Editor-in - Ch ief; 
CDR C.T. Cloutier (MC) 
Aerospace Medicine: CAPT M.G. Webb 
(MC); Dental Corps: CAPT E.E. McDonald 
(DC); Education: CAPT J.S. Cassells 
(MCJ; Fleet Support: CAPT E.W. Jones 
(MC); Gastroenterology: CAPT D.O. Caste]! 
(MC); Hospital Corps: HMCM H.S. 
Anderson; Legal: LCDR R.E, Broach 
(JAGC); Marine Corps; CAPT D.R. Hauler 
(MC); Medical Service Corps: LCDR J.T. 
Dalton (MSC); Naval Reserve: CAPT N.V. 
Cooley (MC, USN); Nephrology: CDR J.D. 
Wallin (MC); Nurse Corps: CAPT P.J. 
Elsass (NC); Occupational Medicine: CAPT 
G.M. Lawton (MC); Preventive Medicine- 
CAPT D.F. Hoeffler (MC); Psychiatry: 
CAPT R.W. Steyn (MC); Research; CAPT 
C.E. Brodine (MC); Submarine Medicine- 
CAPT H.E. Glick (MC) 

POLICY: U.S. Navy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Navy Medical 
Department personnel official and professional information 
relative to medicine, dentistry, and the allied health sci- 
ences. Opinions expressed are those of the authors and do 
not necessarily represent the official position of the Depart- 
ment of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although U.S. Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution list. The following distribution is author 
ized. one copy for each Medical. Dental, Medical Service 
and Nurse Corps officer; one copy for every 10 enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE: All correspondence should he 
addressed to: Editor, U.S. Navy Medicine, Department of 
the Navy, Bureau of Medicine and Surgery (Code 0010). 
Washington, D.C, 20372. Telephone: (Area Code 202) 
254-4253, 254-4316. 254-4214; Autovon 294-4253, 294-4316, 
294-4214. Contributions from the field are welcome and will 
be published as space permits, subject to editing and pos- 
sible abridgment. 

The issuance of this publication is approved in accor- 
dance with Department of the Navy Publications and 
Printing Regulations (NAVEXOS P 351. 



U.S.MVY 




Volume 68, 
April 1977 



Number 4 



1 From the Surgeon General 

2 Department Rounds 

Fleet liaison: covering the waterfront . . . Medical record shape-up 

6 On Duty 

A Flight Surgeon Returns to Sea 
CAPTW.L. McLean, MC, USN 

8 Scholars' Scuttlebutt 

Navy Clinics: A Rewarding Assignment for Specialists 
CAPT R. V. Rack, MC, USN 
CDR L.C. Ellwood, MC, USN 

9 Notes and Announcements 

AMSUS announces awards program . . . W. Graham Claytor Jr is 
new SECNAV . . . FY77 Sailor of the Year competition opens'! , . 
AFIP to offer radiology seminars . , . JUMPS covers all active-duty 
personnel , . . NRMC Portsmouth sets nursing courses . . . Roentgen 
ray society offers award . . . Eight from NRMC Great Lakes earn 
master's degrees , . . Hearing conservation training scheduled . . . 
Dental officers trained in casualty treatment . . . Small passports 
introduced 

12 Features 

For Medical Department women: opportunity and respect 

17 Policy How Medical Department officers are assigned 

18 BUMED SITREP 

19 Enlisted Scene 

NOTAP: What's it all about? . . . Corpsmen, dental technicians now 
in CREO Group D 

20 NAVMED Newsmakers 

21 Professional 

ACustom Staining Technique for Natural-Looking Ceramic Restorations 
LT P,E, Schmid, DC, USNR 

24 Clinicopathological Study of Aortic Valve Replacement 
ENS F.C. Robinson, USNR 

29 Letters 

COVER: LT Dorothy E. Knuppel (DC), of Naval Regional Dental Center 
Charleston, is one of many talented women finding opportunities for pro- 
fessional growth in the Navy Medical Department. U.S. Navy Medicine 
reports on the growing role of Medical Department women beginninq on 
page 12. 



NAVMED P-508B 



From the Surgeon General 



Alcohol: Deglamorizing the Myth 



OVER THE PAST several years, the 
Navy has built an alcohol rehabilita- 
tion program that enjoys a fine rep- 
utation in the professional com- 
munity. By attending special train- 
ing courses, many Navy medical 
officers have developed mature atti- 
tudes toward alcoholics and im- 
proved their skill in bringing these 
men and women to sobriety, later 
applying this knowledge in daily 
clinical practice. Navy alcohol reha- 
bilitation services, centers, and 
units are filled to capacity and the 
waiting lists remain long. 

Now we must focus on prevention 
as well as rehabilitation. It is more 
humane, intelligent, and economi- 
cal to stop people from becoming 
alcoholics, whenever we can, than 
to rehabilitate them. Rehabilitation 
efforts are inevitably associated 
with loss of time and expenditure of 
resources, and are often undertaken 
only when irreversible damage has 
already been done to the alcoholic's 
family, health, finances, and repu- 
tation. Even under the best condi- 
tions, there is a 20% to 30% risk of 
failure. 

Our seafaring tradition includes 
rituals that encourage heavy drink- 
ing as a sign of vigor and good fel- 
lowship. This tenacious myth stems 
from the days of the galleons; it has 
no place in a modern Navy. We in 
the Medical Department must dis- 
pel this folklore not only by what we 
say, but more important, by our 
leadership and our example. I 



therefore urge that we deglamorize 
alcoholic beverages at Medical De- 
partment social functions, official 
and unofficial, from receptions to 
picnics. There is nothing happy 
about the traditional "happy hour" 
ashore where people are encour- 
aged to drink in lieu of more produc- 
tive or wholesome pastimes. Some 
shipmates suffer penalties, injury, 
sickness or death as a result of get- 
togethers where heavy drinking 
prevails with official sanction. 

Drinking patterns vary from base 
to base, and caution must be exer- 
cised lest total prohibition lead to 
severe surreptitious drinking, as it 
tends to do in nominally abstinent 
homes and societies. Medical De- 
partment members should support 
strict enforcement of Control In- 
struction 1503 in the Manual tor 
Messes Ashore, whose key words 
are ". . . abstinence shall at all 
times be encouraged, with modera- 
tion expected. ..." 

The Medical Department must 
take a leading role in curtailing irre- 
sponsible drinking in the Navy. Spe- 
cifically, all Medical Department 
members must act responsibly in 
their consumption of alcohol, or 
avail themselves of rehabilitation. 



ji./J 




VADM Arentzen 




W.P. ARENTZEN 

Vice Admiral, Medical Corps 

United States Navy 



Volume 68, April 1977 




Fleet liaison personnel from NRMC Charleston board submarine to administer swine flu 

Department Rounds 



vaccine 



Fleet Liaison: Covering the Waterfront 



When three Army men contract- 
ed hepatitis aboard a Navy troop 
carrier headed for Fort Lewis, 
Wash., the vessel's concerned sen- 
ior medical officer wired Naval 
Regional Medical Center Bremer- 
ton, where a staff member alerted 
CDR Richard A. Nefson (MC) at his 
home at 2200. By sunrise CDR Nel- 
son had arranged to board the ship 
as it entered Puget Sound. By 0730 
that morning, Dr. Nelson, accom- 
panied by another medical officer 
and a civilian preventive medicine 
specialist, was on board investigat- 
ing the outbreak. After determining 
that mass immunization wasn't 
needed, the investigators made 
plans to evacuate the sick men to 
Madigan Army Medical Center at 
Fort Lewis. 

CDR Nelson is accustomed to 
midnight messages from ships with 
emergency medical needs. It's all 
part of his job as fleet medical 




Physician's Assistant CW02 Rich ex- 
amines patient aboard USS Kitty Hawk 

liaison coordinator for NRMC 
Bremerton, and his staff's readi- 
ness to provide medical services of 
every description, at any hour, lies 
behind the success of the medical 
center's two-year-old fleet liaison 
program. 



"Our job is to help the fleet ob- 
tain the medical services they 
need," says CDR Nelson, who also 
directs the occupational and envi- 
ronmental health service at NRMC 
Bremerton. 

"Before each ship arrives in our 
area, we send the ship's command- 
er a packet of information on ser- 
vices available from the medical 
center," he notes. "Also, our fleet 
medical and dental liaison team 
visits each vessel coming into Puget 
Sound for overhaul, or for any pro- 
longed visit. We meet with the CO, 
executive officer, and senior medi- 
cal representative to describe the 
services we can provide and to dis- 
cuss how we can help them with any 
special needs. We stress that we are 
available around the clock — and the 
ships take advantage of that." 

Waterfront clinic. To make medi- 
cal services more accessible, NRMC 
Bremerton moved military sick call 



U.S. Navy Medicine 




Technician from NRMC Bremerton re- 
views X-ray on board USS Kitty Hawk 



from the medical center emergency 
room to the industrial clinic at Puget 
Sound Naval Shipyard. Most fleet 
units now receive laboratory, X-ray, 
pharmacy, audiometric, and pul- 
monary function screening services 
at this waterfront clinic. 

While a ship is in port, personnel 
from NRMC Bremerton are con- 
stantly going aboard to help out. 
"Our industrial hygienists make un- 
scheduled visits to the ship during 
overhaul and are always available 
on short notice," says CDR Nelson. 
"Our environmental health person- 
nel visit each ship when it arrives in 
the yard and schedule follow-up 
visits to conduct sanitation and 
habitability surveys, and to help 
with pest and communicable dis- 
ease control." 

"When a ship has been com- 
pletely overhauled," he continues, 
"we often send a physician or in- 
dustrial hygienist to accompany it 
on sea trials." NRMC Bremerton 
physicians regularly fill in for physi- 
cians who must be away from their 
ships, and a chief hospital corpsman 




At Puget Sound Naval Shipyard clinic, 
HM2 Crist cares for crewmember 

from the medical center recently re- 
placed a corpsman who was on 
emergency leave when his ship 
went back to sea. 

Medical officers and corpsmen 
assigned to fleet units get priority 
placement in Bremerton's training 



programs so they can keep up with 
the latest medical and surgical tech- 
niques. Crewmembers, too, get the 
red carpet treatment: any man re- 
ferred by his ship's medical depart- 
ment must be seen within five 
working days of the referral, even if 
it means rescheduling appoint- 
ments for dependents and retirees. 
Fleet liaison officers at Bremer- 
ton also function as arbitrators. 
"We are able to prevent minor mis- 
understandings from becoming 
major problems," CDR Nelson 
points out, "by inviting representa- 
tives from fleet units to sit on the 
medical center's consumers' coun- 
cil." 

Shore-based services. The Navy 
Medical Department started the 
fleet medical and dental liaison pro- 
gram two years ago to make it 
easier for ships to secure shore- 
based medical services. Nearly all 
regional medical centers, regional 
dental centers, and hospitals now 
have liaison programs. 

Communication— telling fleet 
units how to get medical help from 
the shore facility— is the key ingre- 
dient in a good fleet liaison pro- 
gram. Briefing teams are a popular 
way to advertise services: a team 
from Naval Regional Medical Cen- 



Volume 68, April 1977 




Orthopedic clinic is held aboard USS Sierra 



ter Naples flies to Rota, Spain, to 
board aircraft carriers entering the 
Mediterranean. The team spends 
three hours on board explaining 
how to secure medical evacuation 
services, what specialists and ser- 
vices are available at the medical 
center, and how to get appoint- 
ments. 

Without special arrangements, 
getting appointments on short no- 
tice can be a problem. The Naples 
solution: when a ship is nearing 
port, the ship's medical department 
sends a message to the medical 
center requesting appointments. 
Patient affairs officers then set up 




the appointments and send the ship 
the appointment schedule and in- 
structions for patients. At Naval 
Regional Dental Center Norfolk, 
Va., the staff arranges blocks of 
dental appointments and mass 
treatment programs for crewmem- 
bers who anticipate a long deploy- 
ment. 

First goal. Some Navy medical 
facilities are taking clinics and 
specialty services right on board — 
or as close as possible. Naval 
Regional Medical Center Charleston 
converted a surplus trailer into a 
hearing conservation van by instal- 
ling five audiometric testing booths. 
The van is parked at pierside so 
crewmembers requiring audiomet- 
ric testing or ear protectors don't 
have far to go for care. NRMC 
Charleston also conducts orthopedic 
clinics on board the USS Sierra for 
SURFLANT ships. 

Such efforts are enabling Navy 
medicine to fulfill its first goal: to 
support the fleet. The payoff is con- 
siderable, if NRMC Bremerton's 
results are any example. CDR 
Nelson reports that fleet liaison ac- 
tivities at that facility have produced 
"better working relationships, an 
easier and sometimes more appro- 
priate provision of services, and 
better support of the Navy's operat- 
ing forces." 

Corpsman vaccinates crewmember 
at Bremerton waterfront clinic 



Medical Record 
Shape-Up 



Sam Slade, private eye, was just 
about to take his raincoat to the 
cleaner when the phone rang. ' 'Mr. 
Slade? This is LT Confused at Naval 
Hospital Lost Gulch. We need your 
help — a patient's health record is 
missing. " 

Slade dashed to the hospital's 
outpatient department. Sure 
enough, the record had vanished. 
In its place was a NA VMED 6150/7 
chargeout card, with no notation 
to indicate who had snatched the 
record. 

Just then, a corpsman dashed in 
clutching the missing jacket. "I 
found it in a branch clinic, ' ' he 
cried. But Slade 's intuition told him 
something was wrong: Where was 
the name of the clinic in which the 
patient was last seen? And who 
had treated the patient? There was 
a signature— but it was illegible. 

For the first time in his long ca- 
reer, Slade was stumped. "This 
beats that Maltese falcon case, " he 
growled. 

No outpatient department ever 
called a private detective to search 
for a missing medical record, but in 
one way, the above story is true: 
records are sometimes lost at Navy 
medical facilities, and crucial infor- 
mation is sometimes illegible, or not 
recorded at all. 

The most serious consequence of 
an improperly maintained health 
record may occur when a former 
Navy member files a claim for com- 
pensation. Information in the health 
records of active-duty personnel 
forms the basis for most claims 
these personnel file with the Veter- 
ans Administration after their re- 
lease from active duty, BUMED of- 
ficials who work with health records 
point out. Information in a health 
record may also play an important 
role in determining a person's 
rights to such benefits as pensions, 

U.S. Navy Medicine 



promotions, and income tax exemp- 
tions. 

BUMED Notice 6150 of 2 Nov 
1976 called for a general shape-up 
of medical records, and outlined 
some of the problems most fre- 
quently found by inspectors and 
auditors. Here are some of those 
pitfalls, and BUMED's advice on 
how to avoid them: 
• A medical record is borrowed, but 
there is no notation on the charge- 
out card to show who took the 
record or where it was taken. 

Whenever anyone checks out the 
health record of an active-duty 
member, he must note the date and 
where he is taking the record on a 
NAVMED 6150/7 chargeout card. 



filed in the patient's record, or is 
filed loosely or out of order. 

Medical record pages should be 
kept in the standard sequence de- 
scribed in Manual of the Medical 
Department Article 16-2, and in 
BUMED Instructions 6322.11 and 
6150. 19A. If information is filed in 
the same sequence in all records, 
anyone needing specific information 
knows exactly where to look. Also, 
pages must be properly attached to 
prevent their falling out when the 
record is carried from one office to 
another. 

• Signatures are illegible, so there 
is no way to determine which medi- 
cal officer, physician 's assistant or 
corpsman saw the patient. 




Proper record maintenance is essential to good patient care 



Usually, the only way to locate a 
borrowed record is by referring to 
this card. 

A standard chargeout card should 
be developed and attached to each 
outpatient record of dependent or 
retired patients. Anyone charging 
out these records can then fill in on 
the card the patient's name and 
family member prefix, the physician 
and clinic borrowing the record, and 
the sponsor's social security num- 
ber. (Chargeout cards are optional 
for small activities where records 
can be controlled without using 
special forms.) 
• Information on medical care is not 



Anyone who makes an entry in 
a health care record should 
type, print, or stamp his or her 
name and rank under the signature. 
Blue or black ink should be used- 
other colors fade quickly and do not 
reproduce well. 

• Treatment information is not kept 
up to date, and there is no provision 
for systematic follow-up of patients. 

Each time a patient is treated, the 
physician should enter in the record 
the patient's complaint or condition, 
the treatment provided, and in- 
structions given to the patient. 
Physical examinations and immuni- 
zations must also be recorded. 



A system should be developed for 
following patients who need special- 
ized examinations, X-rays, or im- 
munizations, or who require follow- 
up tests or examinations because of 
their occupations. 

• Records are kept of patients who 
have been transferred or discharged 
from active duty, and of dependents 
who haven't been treated in three 
years. 

When a Navy member is released 
from active duty, his or her health 
and dental records go with the ser- 
vice record to the Naval Reserve 
Personnel Center in New Orleans. 
For the present, health and dental 
records of Marines separated from 
active duty continue to go to the 
Bureau of Medicine and Surgery. 
For details, see Manual of the Med- 
ical Department Articles 16-9 and 
16-20. 

If dependents or retirees have not 
been treated in a Navy medical 
facility for three years, their records 
should be sent to the National Per- 
sonnel Records Center in St. Louis, 
Mo. See BUMED Instruction 
6322.11 for details. 

• Records are accessible to unau- 
thorized personnel. 

Medical records should be kept in 
a secured area to ensure the con- 
fidentiality of personal information. 

• Dependents' outpatient records 
do not include up-to-date informa- 
tion on their eligibility for Navy- 
sponsored health care. 

The health record of a non-active- 
duty beneficiary must include the 
expiration date of the patient's 
identification card as well as the 
sponsor's identification number, to 
ensure that only eligible beneficiar- 
ies receive care at government ex- 
pense. 

If you aren't sure how to maintain 
or dispose of a medical or dental 
record, don't call a detective — con- 
tact CDR E.E. Rovario (MSC), head 
of the BUMED Records Manage- 
ment Branch, at (Area code 703) 
697-4422, Autovon 227-4422. CDR 
Rovario can answer questions about 
the records of active-duty patients, 
as well as dependent and retiree pa- 
tients. 



Volume 68, April 1977 



On Duty 



A Flight Surgeon Returns 
to Sea 



CAPT Walter L. McLean, MC, USN 



Of what possible use can a bald- 
ing pediatric allergist be aboard an 
aircraft carrier, I wondered, when I 
received orders in 1975 to report 
aboard the carrier USS Independ- 
ence (CV-62) for three months. As 
a participant in the pilot test of the 
fleet medical pool concept, I had 
joined a group of physicians se- 
lected to rotate between Navy medi- 
cal facilities (National Naval Medi- 
cal Center, in my case) and ship- 
board duty. Since I had last prac- 
ticed as a flight surgeon in 1963 — 
during Operation Deep Freeze at 
McMurdo Station, Antarctica— I 
wondered what had possessed the 
Bureau of Medicine and Surgery to 
send me back to sea. Little did I sus- 
pect the unanticipated rewards of 
my experience as a "90-day won- 
der." 

The most difficult preparation 
was announcing to my wife that I 
would be going away again when 
she assumed that my job as an acad- 
emician—training residents and fel- 
lows in pediatrics and allergy- 
made sea duty unlikely. But her un- 
derstanding and strength made our 
separation and reunion tranquil. 

First, I reviewed my notes from 
the basic flight surgeon course. I 
also found the U.S. Naval Flight 
Surgeon 's Manual invaluable for re- 
viewing my future duties and re- 
sponsibilities. 

Preventive medicine. After pass- 
ing my flight physical examination 
and spending a day in physiologic 



CAPT McLean is assistant chairman of the 
Department of Pediatrics and director of the 
Pediatric Allergy Fellowship Program, Na- 
tional Naval Medical Center, Bethesda Md 
20014. 



training at Naval Air Station, Patux- 
ent River, Md., I headed for 
Norfolk, Va. There I attended a two- 
day seminar on shipboard preven- 
tive medicine problems, learning 
how to combat rats, roaches, noise 
and heat aboard ship. I also had a 
chance to visit the medical spaces 
aboard my ship, which helped me 
tremendously in planning my future 
work. As final preparation, I spent 
two mornings in an eye clinic ob- 
serving the work of optometrists 
and reviewing refractive errors and 
phorias. I could easily have used a 
full week of training in an optometry 
clinic. 

When I arrived on board the In- 
dependence, I discovered that as a 
captain 1 outranked the senior medi- 
cal officer, CDR (now CAPT) J.D. 
Morgan (MC). But we worked out a 
division of labor which posed no 
problems: CDR Morgan ran the 
ship's medical department, while I 
functioned as a flight surgeon for 
the squadrons. All four medical 
officers aboard the Independence 
shared duty at sick call, stood on- 
board watches, and performed 
physical examinations. We all inter- 
viewed crewmembers being con- 
sidered for administrative separa- 
tion from the Navy, for the Drug 
Exemption Program, and for refer- 
ral to alcohol rehabilitation pro- 
grams. We all spent time counsel- 
ing crewmembers who had psycho- 
social problems. 

Besides these regular duties, 
CDR Morgan and I visited naval 
hospitals in Rota, Spain, and 
Naples, Italy, to relate our needs for 
specialty consultations for our crew, 
aeromedical evacuations, and other 
medical services. We also offered 



our own specialty services in derma- 
tology and allergy. (During the 
cruise I practiced my specialty by 
completing allergy workups on a 
number of crewmembers, and prac- 
ticed pediatrics in port when crew- 
members' wives and children flew 
to Naples for a Christmas visit.) 

Because of my knowledge of cold 
weather medicine, gained during 
Operation Deep Freeze, I acquired 
the extra responsibility of briefing 
the crew on cold weather hazards 
before we went above the Arctic 
Circle during NATO exercises. As it 
turned out, only one cold weather 
injury occurred during the cruise: a 
crewmember developed mild frost- 
bite of the toes while skiing on 
Mount Etna in Sicily! 

Having come from a teaching 
hospital, I was well prepared to lec- 
ture on medical problems. When I 
first reported on board, the ship's 
physicians were instructing corps- 
men through daily lectures before 
morning sick call. I suggested that 
one physician always be present in 
the sick call triage area to observe 
and train the screeners. The corps- 
men found they could perform bet- 
ter examinations when a teacher 
was present. 

Our lectures to pilots on smoking, 
nutrition, arteriosclerosis, and hy- 
poxia were well accepted. I was also 
asked to speak on medical problems 
related to drug abuse, and learned 
my subject by reading and talking 
with drugtakers themselves. 

Confidence. Perhaps my most re- 
warding experience was getting to 
know the men who face ' 'peril in the 
sky," and a braver, more dedicated 
group I have never known. I shared 
with them the dangers of a "cat 
shot" [catapult shot] and arrested 
landing, and gained their confi- 
dence both as a friend and as a 
health care professional. 

One good way to get acquainted 
with these men was to attend flight 
briefings, and to share their meals 
in the wardroom and the evening 
movies in the ready rooms. Soon I 
began to receive invitations to fly 
with them. But I had a small prob- 
lem: I had been issued only a flight 



U.S. Navy Medicine 




USS Independence (CV-62) underway in the Mediterranean 



suit and boots; before I could fly I 
had to borrow a helmet, oxygen 
mask, and survival jacket. In other 
words, I had to find a pilot my size 
who wasn't flying that day! 

To appreciate the work done 
aboard a carrier, I found it valuable 
to observe as many shipboard activ- 
ities as I could. Standing with the 
flight crew between two screaming 
jets poised on the catapults ready to 
be launched is not the healthiest 
activity, as I learned firsthand. 
Watching a group fire the eight 
chambers in a boiler that holds 1200 
psi of steam, and remembering that 
our ship had had a boiler explosion 
which delayed our deployment, 
made me appreciate the problems 
of working in engineering spaces. I 
visited the paraloft to see para- 
chutes tested, stopped by the liquid 
oxygen plant and the jet engine 
repair shop, and began to get a 
good idea of the work that goes into 
supporting the air group. And after 
I spent time in the combat informa- 
tion center, the carrier air traffic 
control center, and primary flight 
control, I understood better the 
complexities of air control aboard a 
floating airport. 

The young men arriving aboard 
ship experience a tough, disciplined 
routine that differs greatly from the 
independence they previously en- 
joyed. Some have tried drugs and 
go through a painful withdrawal 
when their supply vanishes during 
the cruise. Other crewmembers be- 
come anxious and depressed be- 
cause they are separated from their 
family and friends. A few are totally 
unsuited for adult life, on land or at 
sea — they are immature, and overly 
dependent on others. 



We found many PPD converters, 
but no one had chest X-rays positive 
for tuberculosis. Since we didn't 
have the laboratory equipment to 
confirm active tuberculosis, we 
evacuated to shore facilities any pa- 
tient suspected of having the dis- 
ease; after they were evaluated and 
returned to the ship, we planned to 
follow these patients for one year 
with X-rays and isoniazid treat- 
ment. 

Seven appendectomies and nu- 
merous circumcisions, vasectomies 
and excisions of cysts were per- 
formed during my three months 
aboard. CDR Morgan, a dermatolo- 
gist, removed moles, skin carcino- 
mas and cysts. Warts fell to cryo- 
surgery, done by a corps man every 
Tuesday. With so much surgical 
talent around, I was fortunate to get 
to do even an incision and drainage 
procedure— but that was all right 
with me! 

Paramedical support. I was deep- 
ly impressed with our corpsmen. 
Their concern for patients, devotion 
to duty, and excellent morale made 
medical care during the cruise a 
successful team effort. 

Our laboratory and X-ray person- 
nel surprised me with the scope of 
the work they performed. I sug- 
gested that key lab and X-ray men 
train others to do their jobs, to give 
us backup when the key men were 
absent. Such training was begun 
and worked to our advantage when 
our X-ray technician developed ap- 
pendicitis and had to go ashore at 

Naples. 

Our corpsmen routinely per- 
formed electrocardiographic exami- 
nations and quality control was en- 
sured by having two physicians read 



each electrocardiograph. Our excel- 
lent audiometry equipment enabled 
corpsmen to perform automatic 
audiometric tests in a soundproof 
room. Several flight deck and engi- 
neering department men were 
found to have sensorineural hearing 
loss and were removed from their 
noisy working spaces. Shipboard 
wards and physiotherapy areas 
were well equipped and manned by 
interested, capable corpsmen. 

The corpsmen gave mass im- 
munizations in the mess deck areas 
after it was discovered that one of 
the messmen had hepatitis. We 
called a special all -hands turnout to 
give gamma globulin shots to the 
entire crew. (Naval Environmental 
and Preventive Medicine Unit No. 7 
in Naples supplied us with the large 
quantity of gamma globulin we 
needed.) 

Looking back. 1 benefitted from 
my cruise in many ways I had not 
anticipated. How many people know 
the difference between the aurora 
borealis and the aurora australis 
from personal experience? I do — I 
saw both on my cruise. As a pedia- 
trician interested in adolescent 
medicine, I learned firsthand about 
the drug culture when I detoxified a 
man who had taken an overdose of 
methaqualone. 1 witnessed the diffi- 
culties of the "air boss" as he 
supervised the landing of planes at 
night on a deck pitching and rolling 
on the high seas, and shared his 
satisfaction when the last plane was 
safely aboard. 

Knowledge of the real Navy world 
gave me a special pride in the Navy. 
I developed a greater sensitivity to 
the need to support our men at sea 
in every possible way. Our crew- 
members aboard the Independence 
performed their difficult tasks well 
in an environment fraught with 
danger even for the wary — one pilot 
and his A-7 Corsair II never re- 
turned from a flight- 
Aboard the "Indy," I was able to 
contribute to the welfare of a 
wonderful group of men. I recom- 
mend sea life and the fleet medical 
pool experience to other medical 
officers. 



Volume 68, April 1977 



Scholars' Scuttlebutt 



Navy Clinics: A Rewarding 
Assignment for Specialists 



CAPT Robert V. Rack, MC, USN 
CDR Leslie C. Ellwood, MC, USN 

He's board certified in pediatrics 
and he spends most of his time 
working in the outpatient clinic? 

It is understandable that medical 
students and residents might won- 
der about this, in view of their tradi- 
tional assignment to hospital wards 
and clinics. As board-certified pedi- 
atricians who enjoy practicing our 
specialty in a Navy outpatient clinic, 
we would like to discuss our work 
and perhaps give you a more 
positive outlook on a duty assign- 
ment you may one day receive. 

The satisfactions of practicing 
primary care medicine in an outpa- 
tient clinic are both professional and 
personal. In primary care, physi- 
cians have many chances to practice 
preventive medicine, and to recog- 
nize and treat incipient disease. 
Using a medical history, careful 
examination, basic laboratory infor- 
mation and close follow-up, the pri- 
mary care physician can alleviate 
much physical suffering and help 
patients avoid hospitalization by 
successfully treating them on an 
outpatient basis. Remember: al- 
though providing complex medical 
care in a hospital may be very satis- 
fying to the physician, hospitaliza- 
tion is not necessarily the patient's 
preference. The regional clinic, 
complete with family physicians, 
does not have the sometimes intimi- 
dating "hospital atmosphere" of a 
regional medical center; instead, a 



CAPT Rack is head of the Pediatrics De- 
partment, Admiral Joel T. Boone Clinics, 
Little Creek Amphibious Base, Norfolk, Va. 
23520. CDR EMwood is a pediatrician on the 
staff of the ciinic. 



8 



familiar, friendly atmosphere makes 
the clinic an excellent setting for the 
medical, psychological and family 
counseling so important in medical 
practice. 

Maximum interest. Since, as pri- 
mary care specialists, we are the 
first physicians contacted when a 
medical problem arises, we are free 
to involve ourselves to our maxi- 
mum interest and capacity in our 
patients' treatment. And we can 
practice the full range of our spe- 
cialty by making time in our sched- 
ules for new patients, follow-ups, 
and complex cases. 

There is plenty of opportunity to 
learn and teach during a clinic as- 
signment. You can devise an effec- 
tive postgraduate education pro- 
gram for yourself from lectures 
given by regional medical center 
specialists, from talking with civil- 
ian specialists to whom you refer 
patients, from films, from reports 
on meetings, and from staff mem- 
bers in your own clinic. Instructing 
nurses and corpsmen will help you 
maintain your teaching skills and 
will also improve the quality of care 
provided at the clinic. In our clinic, 
we instruct medical students; at 
other primary care clinics, physi- 
cians may supervise the clinical 
training of residents. 

Satisfaction. Clinic physicians 
have the satisfaction of knowing 
that their assignment meets the 
Navy's critical needs. These physi- 
cians are located near their patients 
but can be drawn into the regional 
center as needed. Assigned to 
clinics, board- certified specialists 
can train nurses, corpsmen and 



ancillary personnel in primary care, 
and can advise general medical 
officers and clinical assistants on 
how to manage illness related to the 
specialty area. The nature of clinic 
practice also gives physicians time 
to get involved in other medical and 
community service activities, to the 
Navy's credit. 

. Disadvantages and irritants are 
inherent in any outpatient practice, 
although we believe they are out- 
weighed by the satisfactions. One 
example: while we are unable to 
admit our own patients to the re- 
gional medical center and treat 
them there, we compensate by 
keeping in touch with the medical 
center physicians who do provide 
the care, and by following our pa- 
tients after their release from the 
hospital. Although the clinic physi- 
cian's skill in treating inpatients 
may suffer somewhat, any rustiness 
can be minimized by rotational as- 
signment to the hospital for ward 
experience. 

In a clinic, with its customary 
large patient load, it may be impos- 
sible to limit the number of patients 
each physician sees in a day. An 
appointment system for acutely ill 
patients is essential to solve this 
problem, as is occasionally referring 
patients who are not very ill to the 
medical center. 

New emphasis. Unfortunately, 
the idea that clinic practice is 
second-class medicine is perpetu- 
ated by physicians who have never 
served in a clinic; subspecialists 
who assume that their days of pro- 
viding primary care are over also 
add to the misconceptions. Yet a 
new emphasis in medical schools on 
ambulatory care is reaffirming the 
importance of the kind of medicine 
practiced in military clinics, 

Clinic practice should be consid- 
ered an opportunity to develop skills 
in outpatient care and to become 
more resourceful. All the satisfac- 
tions of a medical career — the prac- 
tice of good medicine, personal 
involvement with patients, continu- 
ing education, teaching — are avail- 
able to the primary care specialist 
who serves in a Navy clinic. 

U.S. Navy Medicine 



Notes B Announcements 



AMSUS ANNOUNCES 1977 AWARDS PROGRAM 

The Association of Military Surgeons of the United 
States (AMSUS) is accepting nominations for its 1977 
awards, which honor federal health care workers for 
outstanding contributions (see chart, page 10). 

Nominations of Medical Department officers should 
be submitted to the Director, Medical Corps Division, 
Bureau of Medicine and Surgery, 2300 E St. N.W., 
Washington, D.C. 20372, no later than 15 May 1977. 
Nominations should include a summary of the officer's 
qualifications and contributions, and a proposed cita- 
tion. An original and four copies of each nomination 
should be submitted. 

W. GRAHAM CLAYTOR, JR., IS NEW SECNAV 

W. Graham Clay tor, Jr., a railroad executive and 
lawyer who served as commanding officer of three Navy 
ships during World War II, has succeeded J. William 
Middendorf II as Secretary of the Navy. 

A graduate of the University of Virginia and Harvard 
University Law School, Mr. Claytor took a leave of ab- 
sence from his Washington, D.C. law firm to serve on 
active-duty in the Navy from 1941 to 1946. He com- 
manded the USS SC-516, USS Lee Fox and USS Cecil J. 
Doyle and achieved lieutenant commander rank before 
his release from active duty. Mr. Claytor joined the 
Southern Railway System as a vice president in 1963, 
and became chairman of the board in 1976. 




W. Graham Claytor, Jr. 

Volume 68, April 1977 



FY77 SAILOR OF THE YEAR COMPETITION OPENS 

Nominations are now being considered for the FY77 
Atlantic Fleet, Pacific Fleet, and Shore Sailors of the 
Year. Enlisted members in grades E-4, E-5 and E-6 are 
eligible for the awards. Nominees must have been 
selected sailor of the month or quarter during the 24- 
month period ending 31 Dec 1976; units not having a 
sailor of the month or quarter program may nominate 
one person. 

The Sailors of the Year will receive a meritorious pro- 
motion to the next pay grade if they meet minimum 
time in rate and length of service requirements; a trip 
with dependents to Washington, D.C, to receive the 
award; and a paid five-day holiday anywhere in the 
continental U.S. The Atlantic and Pacific Fleet winners 
may choose a year's duty as assistant to the master 
chief petty officer of the fleet; the Shore Sailor of the 
Year may serve a year's duty as assistant to the master 
chief petty officer of the Naval Education and Training 
Command. 

Nominations of Medical Department members for 
Shore Sailor of the Year should be submitted to the 
Bureau of Medicine and Surgery (Code 34) by 18 April, 
in the format described in BUPERS Notice 1700 of 6 Jan 
1977. 

AFIP TO OFFER RADIOLOGY SEMINARS 

The Armed Forces Institute of Pathology (AFIP), 
Washington, D.C, has announced a series of diagnos- 
tic radiology seminars designed to give radiologists an 
overview of the morphological principles used in evalu- 
ating roentgenographic signs. The sessions are: 

2-6 May 1977 Special course on bone and chest. 

11-15 July 1977 Special course on bone and chest. 

19-23 Sept 1977 General course on bone, chest, 
gastrointestinal system, and 
genitourinary system. 

The seminars are approved by the American Medical 
Association for 35 hours of Category I continuing edu- 
cation credit. Applications are available from the 
Director, Armed Forces Institute of Pathology, ATTN: 
AFIP-EDZ, Washington, D.C. 20306. 

JUMPS COVERS ALL ACTIVE-DUTY PERSONNEL 

The Joint Uniform Military Pay System (JUMPS) 
now covers all active-duty military personnel. JUMPS 
provides each Navy member with a monthly leave and 
earnings statement that shows the latest leave bal- 
ance, pay entitlements, and deductions, and forecasts 
of those figures for the next two paydays. Conversion to 
JUMPS began in January 1976 and was completed in 
January 1977. 



AMSUS Awards Summary 

Tile table shown below and the following pages outline the awards program for 1977 



AWARD TITLE 



The John Shaw Billings Award 



INITIATED BY 



Eaton Laboratories Div., 
Norwich Pharmacal Co. 



**The Joel T. Boone Award 



The Ray E. Brown Award 



The Andrew Craigie Award 



Ciba Pharmaceutical Co., 
Div. Ciba-Geigy Corp, 



ACHIEVEMENT RECOGNIZED 



AMSUS member under 41 for outstanding potential in 
Executive Medicine. 



Outstanding service to the Association. 



Bcecham Laboratories 



Lederle Laboratories Div. 
American Cvanamid Co. 



The Federal Medical Resi- 
dents Award 



The Federal Nursing Service 
Award 



*The Founder's Medal 



Purdue Frederick Company 



Outstanding accomplishments in Federal health care 
management. 



PRIZE 



Plaque; $500. 



Silver plaque; $500. 



Bronze piaque; $1,00( 



Outstanding accomplishment in advancement of profes- 
sional pharmacy within the Federal government. 



Federal Medical Resident nominated by one of the 
Federal medical chiefs for outstanding performance as 
a resident. 



Roche Laboratories Div. 
Hoffmann-LaRocbe, Inc. 



Executive Council, AMSUS 



The Donald H. Gaylor Award 



The Gorgas Medal 



The Philip Hcnch Award 



DOW Lepetit USA 



Wyeth Laboratories of 
Philadelphia 



Best essay submitted in competition, advancing profes- 
sional nursing. 



Outstanding contribution to military medicine and 
meritorious service to the Association. 



Silver plaque; $500. 



Plaque; $500. 



Plaque; S500. 



Outstanding contributions by a federal physician in the 
field of tuberculosis 



Merck, Sharp & Dohme 



The James A. McCallam 
Award 



"The William C. Porter 
Lecture 



The MAJ Louis Livingston 
Seaman Prize 



**The Sustaining Membership 
Lecture Award 



Norden Laboratories of 
Smith Kline & French 
Laboratories 



Distinguished work in preventive medicine. 



Outstanding contributions in field of rheumatology and 
arthritis. 



Bronze medal; Scroll, 
Life membership. 



Piaque; $1,000. 



Silver medal; Scroll; 
$500. 



Bronze plaque; $1,000. 



Outstanding accomplishment in the field of medicine 
and health by a Doctor of Veterinary Medicine eligible 
for AMSUS membership 



Geigy Pharmaceuticals Di- 
Ciba-Geigy Corp. 



AMSUS Trust Fund left by 
MAJ Seaman 



The Sir Henry Wellcome 
Medal & Prize 



*The Paul Dudley White 
Award 



The MAJ Gary Wratten 
Award 



Sustaining Members, 
AMSUS 



William C. Porter Lecture, on psychiatry, at Annual 
Convention, 



Notable article published in MILITARY MEDICINE 
during the previous calendar year. 



Plaque, $500. 



Scroll; $750. 



Scroll; $250. 



Sustaining Membership lecture by AMSUS member, on Scroll; $500. 
medical research, at Annual Convention. 



Estate of Sir Henry 
Wellcome 



USV Pharmaceutical Corp. 



Garret Corporation 



Winning competitive essay on any subject relating to 
military medicine. 



Outstanding accomplishment in the field of Cardiovas- 
cular disease by person eligible for AMSUS membership. 



Outstanding accomplishment in field military medicine 
by person eligible for AMSUS membership. 



Silver medal; Scroll; 
$500. 



Scroll; $1,000. 



Bronze plaque; $500. 



Nominations for 1977 awards recipients are currently being considered by Commanders and Directors of Federal Medical Facilities. Nominations 




and the Boone Award, which is selected by the Executive Director, as ratified by the Executive Council 
"New award for 1977. 



Progran 



* non-competitive. 

10 



Reprinted from Military Medicine, Vol. 141, No. 1, January 1977. 

U.S. Navy Medicine 



NRMC PORTSMOUTH SETS NURSING COURSES 

The following courses for Navy nurses and paramedi- 
cal nursing personnel will be given at Naval Regional 
Medical Center Portsmouth, Va. in 1977 and 1978. For 
further information contact LCDR Shirlee C. Hicks, NC, 
USN, Educational Coordinator, NRMC Portsmouth, Va. 
23708. 

1977 

1-19 August Coronary care workshop for nurses 

(90 contact hours) 

19-30 September Critical care workshop for nurses 

{60 hours) 

21 October Fourth annual nursing symposium: 

"Evaluation Process" (6 hours) 

31 October-18 November Coronary care workshop for para- 
medical nursing service personnel 
{90 hours) 

28 November-2 December Critical care workshop for para- 

medical nursing service personnel 
(60 hours) 
1978 
24 April-12 May Coronary care workshop for para- 

medical nursing service personnel 
(90 hours) 

29 May-2 June Critical care workshop for para- 

medical nursing service personnel 
(60 hours) 

ROENTGEN RAY SOCIETY OFFERS AWARD 

The American Roentgen Ray Society offers an annual 
award for the best paper submitted on a clinical appli- 
cation of radiology. Manuscripts should not have more 
than 5,000 words or ten illustrations. The winner will 
receive a certificate and an honorarium of $1,000; the 
winning paper will be presented at the Society's annual 
meeting and submitted for publication to the American 
Journal of Roentgenology. 

To apply for the award, send three copies of your 
paper and illustrations to A. Everette James, Jr., M.D., 
Chairman, Research and Education Committee, Ameri- 
can Roentgen Ray Society, Department of Radiology 
and Radiological Sciences, Vanderbilt University 
Hospital, Nashville, Tenn. 37232. The application dead- 
line is 1 May, and the winner will be announced by 15 
July. 

EIGHT FROM NRMC GREAT LAKES 
EARN MASTER'S DEGREES 

Eight staff members of Naval Regional Medical 
Center Great Lakes, 111., have received M. A. degrees in 
health facilities management from Webster College, St. 
Louis, Mo. The graduates earned their degrees by at- 
tending a special Webster College program held in the 
Great Lakes area. The program, which is accredited by 
the American College of Hospital Administrators, is 
also offered at Scott Air Force Base in Belleville, 111., 
and Fitzsimons Army Medical Center in Denver. 

Volume 68, April 1977 



The graduates are Medical Service Corps officers 
CDR N.C. Lachapelle, LCDRs J.E. Shepherd and H. 
Yates, Jr., and LTs R.A. Fink, C.H. Pointer IV, and 
R.E. Streumpler; Nurse Corps officer LCDR D.L. Mc- 
Kinney; and M. Shantinath. 

HEARING CONSERVATION TRAINING SCHEDULED 

A hearing conservation technician course will be 
offered 25-29 July 1977 at the Naval Aerospace Medical 
Institute, Pensacola. Naval regional medical centers 
that require such training for their personnel should 
notify BUMED Code 55 and send a copy of their request 
to the Commanding Officer, Naval Aerospace Medical 
Institute (Code 05), Pensacola, Fla. 32308. 

DENTAL OFFICERS TRAINED IN 
CASUALTY TREATMENT 

Twenty Navy dental officers completed a casualty 
treatment training course held 24-28 Jan 1977 at Naval 
Regional Dental Center Norfolk, Va. In the course, 
dental officers learn emergency casualty treatment so 
they can augment medical efforts during combat. 
Similar courses are held at Great Lakes, 111., and San 
Diego, Calif. 

Course graduates included the following Navy dental 
officers: CAPT R.J. Koss; CDRs C.E. Branyan, M.T. 
Ridley, and R.H, Harper; and LCDR G.A. Kurtz. Naval 
Reserve dental officers who completed training were 
LCDRs R.J. Glenn and W. Dvorak and LTs S.D. Cooke, 
J.K. Dowling, S.H. Nightingale, D.J. Singsank, A.F. 
Creal, Jr., E.D. Brinkley, Jr., A.T. Benson, K.M. 
Harrison, W.J. Kibbey, L.W. Jackson, T.L. Sutton, and 
M.J. Minarchek. LCDR L.J. Marconyak, DC, USNR-R 
also completed this training. 

SMALL PASSPORTS INTRODUCED 

Like candy bars, calculators, and the size of the 
American family, the passport is shrinking. 

On 1 Jan 1977, the U.S. Passport Office began is- 
suing passports measuring 3Vi inches by 5 inches. The 
new passports conform to international standards, thus 
simplifying passport inspection at points of entry into 
foreign countries. The reduction in size is expected to 
save the U.S. Government nearly $200,000 a year in 
printing costs. 

The new passports are issued in three categories: 
regular (with a blue cover), official (maroon cover), and 
diplomatic (black cover). All three types are valid for 
five years from date of issue, unless otherwise 
indicated. 

The regular passport issuance fee of $10 is not 
charged to military or civilian personnel and their 
dependents who are traveling under official govern- 
ment orders. Authorization forms (DD Form 1056) for 
obtaining these free passports are available from pass- 
port assistance offices on military bases. 

II 




Today Navy women serve in nearly every health care field: (clockwise 
from top left) Navy nurses care for newborn in intensive care unit; 
LTJG Doris Forte (MSC), Navy's first black woman optometrist, on 
the job at NRMC San Diego; dental technician teaches oral hygiene 
during National Children's Dental Health Week; LT Carolyn Stagner 
CMC) trains in the NNMC lab as part of her pathology residency; 
Navy occupational therapist works with a patient. 







12 



U.S. Navy Medicine 



Features 



Medical Department Women 



For Talented Trailblazers: Opportunity and Respect 



A startled patient once looked up 
from the dental chair as LT Dorothy 
E. Knuppel (DC) reached for the 
drill, and asked, "Have you done 
this before?" But that was an ex- 
ception: most of her patients take a 
woman dental officer in stride. A 
1975 graduate of the University of 
Pennsylvania Dental School, LT 
Knuppel practices at Naval Region- 
al Dental Center Charleston, and 
plans to specialize in prosthodon- 
tics. "I felt that the Navy had the 
most to offer in the field of den- 
tistry, and 1 liked the choices of 
duty," she says. 

LT Knuppel is one of scores of 
talented women who are making a 
name for themselves in the Navy 
Medical Department. Today Navy 
women serve in every health care 
field not associated with combat 
vessels. 

In the Medical Corps, the number 
of women has increased from 1 in 
1948 to today's 105 active-duty 
women medical officers, including 
four captains. Typical of these dedi- 
cated women is psychiatry resident 



LCDR Becky Brinegar (MC), the 
only woman on the psychiatric staff 
of National Naval Medical Center. 

"In general, my being a woman 
hasn't gotten in the way when I deal 
with patients or colleagues," LCDR 
Brinegar says. Colleagues, she 
admits, were curious about her be- 
fore she arrived: "They'd never 
come across a female 'shrink' in the 
service, and they were dying to find 
out what I'd be like." And one or 
two patients didn't realize she was a 
physician: "There are always those 
times when you walk on the ward in 
your white uniform," she says, 
"and somebody calls 'Hey, 



nurse! 



Career plans. The one time being 
a woman seriously impeded Dr. 
Brinegar' s goals was when she 
asked to be assigned to the only 
psychiatry billet at Naval Regional 
Medical Center Okinawa. She was 
accepted on the basis of her qualifi- 
cations, but the assignment was 
later vetoed because, as a woman, 
she could not deploy with Marine 
units if a psychiatrist were needed. 




Volume 68, April 1977 



She has since asked for an assign- 
ment to the alcohol rehabilitation 
unit at Naval Regional Medical 
Center Camp Lejeune, and plans to 
make her career in the Navy. "1 like 
the Navy," she says. "It offers me 
the training I want in psychiatry." 
Also happy with her Navy experi- 
ence is CDR Alice M. Martinson 
(MC), chief of the Orthopedics Ser- 
vice at Naval Regional Medical 
Center Long Beach. The only female 
orthopedist in the Navy, she is one 
of two women at the helm of a spe- 
cialty service in a Navy medical 
facility. (The other is CAPT Betty 
Meriwether (MC), chief of the Ob- 
stetrics and Gynecology Service at 
Naval Regional Medical Center 
Philadelphia.) "I'm very satisfied," 
says Dr. Martinson. "In medical 
school and in the Navy, I have never 
been treated with anything less 
than respect." Patients, she says, 
accept her but may be caught off 
guard at first. "I think if they're not 
expecting a woman, I catch them a 
little off balance. Then, by the time 
they recover from their surprise 
enough to comment, it's too late — 
they're out of the office!" 

A Navy-sponsored graduate of 
George Washington University 
Medical School in Washington, 
D.C., Dr. Martinson served her 
internship and residency in orthope- 
dics at Naval Regional Medical 
Center San Diego. She went to 
NRMC Long Beach in 1974 and two 
years later became chief of her ser- 
vice, which includes three other 
orthopedists. Pleased with her job, 
she hopes to move into executive 



LT D.E. Knuppel (DC) 
"Navy has the most to offer" 

13 



medicine, which she calls "very in- 
teresting and challenging." 

Dr. Martinson recommends the 
Navy to women contemplating a 
medical career because "Navy resi- 
dency programs are outstanding. 
You're working with the patient 
from day one, instead of first meet- 
ing your patient the day before sur- 
gery." 

Critical specialties. Public Law 
38, enacted in April 1943, first 
opened the Medical Corps to women 
— and then only temporarily — by 
allowing women to serve in certain 
critical specialties for the duration 
of World War II. Enacted as emer- 
gency wartime legislation, the law 
was repealed in 1947. But one year 
later the Women's Armed Services 
Integration Act decreed that "all 
laws . . . which authorized ... ap- 
pointments of commissioned and 
warrant officers in the Regular Navy 
shall ... be construed to include 
authority to enlist and appoint 
women in the Regular Navy." 
Frances L. Willoughby, M.D., of 
Pitman, N.J., was appointed a lieu- 
tenant commander — the highest 
rank open to women — in the Medi- 
cal Corps in October 1948, becom- 
ing the first woman to serve as a 
physician in the regular Navy. 
Legislation was later enacted allow- 
ing women to attain captain's and 
flag rank. 

The law that today bars women 
from serving in combat-related jobs 
has not stopped women physicians 
from filling operational medical bil- 
lets. In 1974, LCDRs Jane O. Mc- 
Williams and Victoria Voge became 
the Navy's first women flight sur- 
geons after graduating from the 
Naval Aerospace Medical Institute 
in the top half of their class. Today 
Dr. Voge is the first and only 
woman entered in a Navy-sponsored 
aviation medicine residency, while 
Dr. McWilliams is the flight sur- 
geon for Training Wing 6 in Pensa- 
cola, Fla. They're no longer alone: 
the Medical Corps now boasts five 
other women flight surgeons. 

The first woman dentist to serve 
in the Armed Forces was LT Sara G. 
Krout (DC) of the Naval Reserve, 



who was on active duty at Great 
Lakes from 1944 to 1946. She re- 
tained her commission in the Re- 
serve until she retired as a com- 
mander in December 1961. The 
Navy's second woman dentist, 
LTJG Elizabeth A. Tweed, was 
commissioned in 1944 and served 
almost two years at Naval Hospital 
San Diego. After these two officers 
left active duty, the Dental Corps 
was all-male until 1969, when Dr. 
Helen Paulus came on active duty. 
The Navy now has six female dental 
officers and sponsors 19 women 
dental students who will join the 
staffs of Navy dental facilities when 
they complete training. 




LCDR J. McWilliams (MC) 

One of five women flight surgeons 



Reaction mixed. LT Birute A. 
Balciunas (DC), who was a Navy- 
sponsored scholarship student in 
dental school, says "the Navy schol- 
arship program for dental students 
is excellent." Although she is the 
only woman officer ever to serve at 
her current duty station, the Marine 
Corps barracks in downtown Wash- 
ington, D.C., she says, "I have no 
problem with patients. Marines are 
gentlemen, let me tell you." 

But the reaction from male dental 
officers has been mixed. "It's just 
difficult for some of them to accept a 
woman dental officer," she says. 
"When I worked at one clinic, there 
was a little too much fatherly con- 



cern. They'd stop by 25 times a day 
to see how I was doing." Dr. 
Balciunas thinks women will be 
more easily accepted in the Dental 
Corps when there are more female 
dental officers. 

While women dentists have been 
relatively rare in the Navy, women 
have served as dental technicians 
since the rating was established in 
1948. By 1969 the Navy had its first 
female master chief dental techni- 
cian, DTCM Johnnie L. Davis. To- 
day, 621 or 15% of the Navy's 3,742 
dental technicians are female, in- 
cluding four chief dental techni- 
cians. 

Women are no longer scarce in 
the Medical Service Corps, either. 
Today's Medical Service Corps in- 
cludes ten women health care ad- 
ministrators, four female pharma- 
cists, and four women optometrists. 
Another 23 women are biologists, 
psychologists, medical technolo- 
gists and specialists in other medi- 
cal allied sciences, while 59 women 
serve as dietitians and occupational 
and physical therapists. Altogether, 
100 of the 1,763 Medical Service 
Corps officers now on active duty 
are women. 

The story of CAPT Kay Keating 
(MSC), the Navy's first woman 
pharmacy officer, shows how one 
woman forged a career in the Medi- 
cal Service Corps and encouraged 
the acceptance of women officers as 
equal partners in Navy medicine. 
When World War II ended, CAPT 
Keating, then a radioman second 
class, returned to college to earn a 
B.S. degree in pharmacy. She then 
reenlisted, hoping to join the Hos- 
pital Corps, but was again assigned 
to radio work. In 1953, when a criti- 
cal shortage of hospital corpsmen 
arose, she changed her rating to 
hospital corpsman first class and 
two months later advanced to 
ensign — the first woman to be com- 
missioned a naval pharmacy officer. 
In December 1953, as an ensign, 
she reported aboard the Navy hos- 
pital ship USS Haven, which 
promptly deployed to Korea. While 
female Nurse Corps officers had 
long been assigned to hospital 



14 



U.S. Navy Medicine 



ships, CAPT Keating's tour in the 
Haven was a first for Medical Ser- 
vice Corps women, and a highlight 
of a successful career that ended 
with her retirement in 1972. 

Competent. More than two dec- 
ades later, MSC women are still 
trailblazers. Take LTJG Doris Forte, 
the Navy's first black woman op- 
tometrist. In 1976 Dr. Forte chose to 
go Navy because "I w inted to travel 
and see some of the world, and the 
Navy seemed the way to do this." 

"Being the first black woman in 
Navy optometry doesn't bother 
me," Dr. Forte says. "A lot of times 
1 have found myself looking around 
for another female optometrist in 
the office, but I've gotten used to 
being the only woman on the staff. 

"Convincing some men that you 
are just as competent as they are is 
sometimes a problem," she notes. 
"But 1 feel that my work is re- 
spected by the men I work with, and 
I appreciate that. I'm a female part 
of the team." 

Other memorable Medical Ser- 
vice Corps women include: 

• Dr. Mary Faye Keener, a distin- 
guished aviation physiologist, who 
in 1965 became the first woman 
MSC officer promoted to the rank of 
captain while on active duty; she 
was also the first woman named a 
fellow of the Aerospace Medicine 
Association. 

• ENS Gale Gordon, an aviation 
experimental psychologist in the 
Naval Reserve, who was the first 
woman to complete flight training in 
the Navy and win her naval aviator 
wings. 

• LTJG Noreen Considine (MSC), 
who in 1973 became the Navy's first 
female industrial hygienist; she is 
now stationed at the Navy Environ- 
mental Health Center in Cincinnati. 
The first Navy nurses — all female 
— were a superintendent, a chief 
nurse and 18 nurses who in 1908 
paid their own way to Washington 
for entrance examinations. These 
enterprising women rented a house, 
established their own messing facil- 
ity, and began the work that is 
carried on today by their succes- 
sors. 




Medical Department women who made history: 
(clockwise from top left) CAPT Keating; RADM 
Duerk; one of first 20 Navy nurses, serving in 
field hospital; LTJG Tweed; HM1 Flora; sea- 
going Navy nurse aboard USS Repose 



Volume 68, April 1977 



15 




HN Stevens ensures a baby's first days 
of life are contented ones 

In World War I, more than 1,400 
Navy nurses served in medical facil- 
ities worldwide, and four nurses 
won the Navy Cross. Afterwards the 
number of Navy nurses dropped to 
less than 500, until World War II 
again brought them to the front 
lines of patient care. In those war 
years and immediately after, the 
official status of Navy nursing was 
established: legislation in 1942 gave 
nurses military rank in temporary 
grades from ensign to captain, and 
in 1947 the Army-Navy Nurse Act 
established the Nurse Corps as a 
staff corps and authorized perma- 
nent commissioned rank. 

Male nurses came on board in 
1965, but women still make up 
nearly 82% of the corps. Navy 
nurses are involved in all areas of 
inpatient and ambulatory health 
care. Besides providing care in 
every clinical specialty, nurses are 
assigned to operating room man- 
agement, anesthesiology, research, 
teaching and administration. An in- 
creasing number of nurses devote 
their energies to providing primary 
care in clinics and outpatient ser- 
vices. 

Top executives. In recent years 
Navy nurses have seized opportuni- 
ties to assume new roles as nurse 
practitioners, nurse midwives, ad- 



ministrators of Navy medical facili- 
ties, and top Medical Department 
executives. CAPT Bernadette Mc- 
Kay was the first Nurse Corps offi- 
cer to be named director of adminis- 
trative services at a Navy health 
care facility, assuming that role in 
1975 at the Naval Submarine Medi- 
cal Center, Groton, Conn. Also in 
1975, CAPT Harriet A. Simmons 
reported to the naval clinic in May- 
port, Fla., to become the first nurse 
serving as officer-in-charge of a 
Navy health care facility. The 
Navy's first woman admiral was a 
Nurse Corps officer: RADM Alene 
B. Duerk (NC), named director of 
the Navy Nurse Corps in 1972. Her 
successor, RADM Maxine Conder 
(NC), now heads a Nurse Corps 
comprising more than 2,500 offi- 
cers. 

In the Hospital Corps, too, 
women provide such vital service 
that it's hard to remember they 
are relative newcomers who were 
first enlisted during World War II. 
In the early 1940's, women with 
training or experience in first aid, 
home nursing, social work, and 
general duty or clerical work in 
hospitals or doctors' offices were 
urged to join the Hospital Corps. 
Also, by December 1942, some 100 
professionally qualified women 
technicians in the clinical labora- 
tory, dental technology, X-ray, 
physical therapy and occupational 
therapy fields had enlisted. In 1944 
the first Hospital Corps school for 
WAVES was commissioned at Na- 
tional Naval Medical Center and 
accepted a charter class of 230 
enlisted women. 

Public Law 625, approved 12 June 
1948, made the WAVES part of the 
regular Navy. That same day, the 
first six women were sworn in as 
Hospital Corps members, with HM1 
Ruth Flora the first in this group to 
take the oath of office. 

Today, women may serve in all 
Hospital Corps specialties except 
those identified with combat ves- 
sels. Hospital Corps women work as 
X-ray, laboratory, ophthalmology, 
dermatology, pharmacy, physical 
therapy and inhalation therapy 



technicians, as well as in many 
other essential health care jobs. 
Many Hospital Corps women ad- 
vance into more specialized fields of 
health care, and some, like LT 
Donna R. Martin (MSC), obtain col- 
lege degrees and accept commis- 
sions as Medical Department offi- 
cers. LT Martin's appointment as 
ensign in 1971 marked the first time 
an enlisted Hospital Corps woman 
was selected through the in-service 
program for commissioning in the 
Medical Service Corps Health Care 
Administration Section. 

A little extra. The highest ranking 
woman in the Hospital Corps today 
is HMCM Ann Mariotto, assistant 
chief of the Military Personnel Ser- 
vice at Naval Regional Medical 
Center Bremerton, Wash. "I found 
out one thing early in the Navy," 
Master Chief Mariotto says. "If you 
do your work and you're willing to 
do a little extra, you'll be ac- 
cepted." 

Master Chief Mariotto attributes 
her successful career to her willing- 
ness to do whatever her job re- 
quired. "I've always performed the 
duties of my rate. Also, I've had of- 
ficers and chiefs who gave me a fair 
deal." She also believes she got a 
lucky break: "When I enlisted in 
1958, I had a little lab training and 
the Navy needed lab technicians, so 
I ended up working in a 'male' field. 
I was never limited to ward duty." 
"In 1960 I put in for radioisotope 
school," she remembers. "I got 
back a letter saying I couldn't go, 
due to the minimal need for women 
in radioisotope training. But since 
then, there's been great improve- 
ment in what Hospital Corps women 
are allowed to do." 

Master Chief Mariotto— and 
other Medical Department women 
—still cannot be assigned to a 
warship or to combat duty. But even 
with that one restriction, there are 
innumerable opportunities for wom- 
en to serve and to grow profession- 
ally in the Navy health care system. 
The rewards are great: as CDR 
Martinson of NRMC Long Beach 
says, "I wouldn't trade what I've 
got with anybody." 



16 



U.S. Navy Medicine 



Policy 



How Medical Department Officers Are Assigned 



Medical Department officer assignment policies are 
based on the Bureau of Naval Personnel (BUPERS) 
Manual, BUPERS instructions and directives, Secretary 
of the Navy instructions, and permanent change of sta- 
tion move limitations directed because of fiscal con- 
straints. There continue to be many requests for 
exemption from assignment policies. BUMED detailers 
intend to assign each officer fairly by adhering to the 
sound management policies explained below: 

• Decisions on assignment of Medical Department 
officers must be based on the needs of the Navy as 
demonstrated by a valid, vacant billet; the officer's 
career development; and the Officer's Preference and 
Personal Information Card. Once an officer has been 
notified of intent to issue orders, requests to cancel or 
modify those orders are considered requests for exemp- 
tion from assignment policy. 

• Medical Department officers will not be considered 
for reassignment until they have a valid projected rota- 
tion date. Tour lengths are determined and projected 
rotation dates assigned in accord with BUPERS policy: 
normal tours for lieutenant commander and above are 3 
to 4 years; tours for lieutenant and below are 2 to 3 

years. 

• Assignments entailing cross-country moves will 
normally be limited to the few situations in which no 
other qualified officer is available to fill a vacant billet. 
Occasionally cross-country moves may be authorized to 
meet Navy needs. 

• Assignment to an overseas facility will be limited to 
unaccompanied officers and officers with no more than 
three dependents. However, officers with children or 
dependent parents are not exempt from assignment 
overseas. Overseas tours commence on the day officers 
leave the continental U.S. Hawaii and Alaska are con- 
sidered overseas tours. 

• To promote command stability and maintain ade- 
quate staffing levels, BUMED usually will not endorse 
a request for reassignment until the officer has com- 
pleted at least one year at a duty station. 

• When reassignment is requested before a regular 
rotation date because of a documented hardship, no- 
cost-to-the-government orders may be issued, unless 
the officer is approaching a valid projected rotation date 
when he or she makes the request. Requests for no-cost 
orders will not be favorably endorsed for any reason 
other than a documented hardship. 

• Requests to change a projected rotation date must be 
made in writing, via the chain of command, six months 
before the normal projected rotation date. Specific 

Volume 68, April 1977 



reasons for such a request must be given, particularly if 
an extension of the normal, established tour length is 
involved. Requests to extend overseas tours beyond 48 
months must be favorably endorsed by an appropriate 
flag or general officer in the field; merely indicating 
this endorsement on a preference card is not sufficient. 
Lengthy extensions of tours in especially desirable 
areas normally will not be granted. To do so would 
delay or negate another officer's opportunity for such 
an assignment. 

• Approval of a request for transfer or extension will 
not be granted at the expense of the career needs of 
another officer. 

• Married officers may anticipate assignment to the 
same location as their spouse provided there is a valid, 
vacant billet for which they are qualified, and provided 
there is a need to have the billet filled. However, the 
fact that an officer is married cannot be the determining 
factor in his or her assignments. To assist detailers in 
responding to requests for concurrent duty, a military 
married couple must notify their respective detailers as 
soon as possible of a move projected for either member. 

• Medical Department officers should submit requests 
for extension of active duty to the Chief of Naval Per- 
sonnel, via BUMED (Code 312), at least eight months 
but no later than three months before their normal 
release from active duty date. 

• Reserve officers appointed before their 26th birthday 
are not eligible to resign until the sixth anniversary of 
their original commissioning date. They may request 
release from active duty prior to that time if they have 
fulfilled all commitments incurred as a result of Navy- 
subsidized education, an initial active-duty obligation, 
an extension of active duty, or another commitment to 
serve on active duty. For details, see BUPERS Manual, 
Article 3830100. 

• Early release for the purpose of entering graduate 
medical education is not being granted by the Chief of 
Naval Personnel (see ALNAV 082/76). 

• An officer is not eligible to resign until two years 
from the date he or she accepted a regular Navy com- 
mission as a result of an augmentation request. 

• A request for resignation or retirement will not be 
considered until the officer has completed one year at a 
duty station in the continental U.S., or, if assigned 
overseas, until completion of that tour. 

Policies regarding augmentation are discussed in 
BUPERS Manual, Article 1020120. Policies on separa- 
tion of dependent and pregnant members can be re- 
viewed in BUPERS Manual, Article 3810170. 



17 



All Medical Department officers should give assign- 
ment officers current, pertinent information that might 
affect their assignability. Medical officers should en- 
sure that their commands forward copies of reporting 
and detachment endorsements, acceptances of aug- 
mentation, and promotion appointments to BUMED 
(Code 312). Information which should be provided in 
the "Remarks" section of an updated preference card 
includes: number and age of children; spouse's name, 
occupation (if civilian), rank/rate year group, social 
security number, designator, rotation date, duty sta- 
tion, and name and telephone number of detailer; 
spouse's school completion date (if a student); spouse's 
estimated dates of hospitalization, if pregnant. 



Because assignments are planned and nominations 
made as much as six to nine months before the 
projected rotation date, early submission of the Officer 
Preference and Personal Information Card is impera- 
tive. The number of Medical Department officers 
married to other active-duty military members is in- 
creasing steadily; officers anticipating marriage should 
remember that assignment to the same duty station as 
their spouse cannot be guaranteed because limitations 
on Medical Department strength do not permit assign- 
ment in excess of allowance. 

Commands are requested to disseminate this infor- 
mation to all Medical Department officers.— BUMED 
Code 3. 



BUMED SITREP 



FROM ARMY TO NAVY . . . Naval Re- 
gional Medical Center Yokosuka, Ja- 
pan, has taken over operation of the 
Army laboratory at Sagami-Ono near 
Camp Zama. This facility, which pro- 
vides laboratory support for all military 
medical activities in the Far East, in- 
cludes a blood bank and blood distribu- 
tion center, a drug screening section, 
and chemistry, pathology, entomology, 
and microbiology departments. There 
are also sections fm research in veteri- 
nary medicine, food inspection, and 
sanitation. CDR Stuart H. Myster (MC), 
designated officer-in-charge, will super- 
vise a staff of nine Navy officers, 29 en- 
listed personnel, and 84 civilians. 

NEW FLAGS ... Six Medical Depart- 
ment officers have been selected for 
flag rank. The new rear admiral select- 
ees are Eustine P. Rucci, George E. 
Gorsuch, and Roger F. Milnes from the 
Medical Corps, Julian J. Thomas, Jr., 
from the Dental Corps, and Naval 
Reservists Matthias H. Backer, Jr. 
(MC) and William J.H. Vaughn (DC). 
Watch for details next month in U.S. 
Navy Medicine. 

NEW PARASITE IDENTIFIED . . . 

Navy scientists have isolated and identi- 
fied the adult worm of a previously un- 
known filarial parasite that causes 
elephantiasis. Investigators at the Naval 
Medical Research Unit No. 2 detach- 
ment in Jakarta, Indonesia, have devel- 
oped animal models for the filaria, 
named Brugia timori, as well as for 
Brugia malayi, one of two other filariae 
which infect humans. Using these 
models, researchers will learn more 



about the pathophysiology of filariasis, 
test chemotherapeutic agents, and de- 
velop a vaccine to protect people from 
filariasis infection. 

OPTOMETRY BILLETS RESTORED 

. . . Nineteen Medical Service Corps 
active-duty optometry billets deleted 
from the Medical Department's FY77 
budget have been restored. This in- 
crease in optometrists will enable the 
Medical Department to provide opto- 
metric services at former levels to all 
eligible beneficiaries. 

It will take some time to recruit 
optometrists to fill the 19 billets; as new 
optometry officers are obtained, they 
will be assigned to activities with the 
greatest need. 



STAMP OF APPROVAL ... The Ocular 
Technician School at the Naval School of 
Health Sciences in San Diego has been 
accredited by the Joint Commission on 
Allied Health Personnel in Ophthalmol- 
ogy. Accreditation means that Navy- 
trained ocular technicians meet stand- 
ards set by the Commission, an inde- 
pendent group of eight physicians from 
national and international ophthalmol- 
ogy societies. 

AUDIT TD?S . . . Navy medical facilities 
can conserve energy by: 

• Closing areas that are seldom used. 

• Reducing use of electricity for light- 
ing and ventilation. 

• Encouraging employees to form car- 
pools and thus save fuel. 




TOP NOTCH DESIGN . . . This branch clinic in the headquarters area of 
Marine Corps Base Camp Pendleton, Calif., was one of six new military 
buildings to win a COD 1976 Design Award for Military Construction. 
Competition judges praised the clearly organized plan and imaginative 
landscaping of the year-old facility. 



18 



U.S. Navy Medicine 



Enlisted Scene 



NOTAP: WHAT'S IT ALL ABOUT? 

It sometimes seems that the same 
personnel research programs, like 
cookbooks, keep reappearing with 
new titles, and that the researchers 
promise better results by using new 
techniques on the same old ingredi- 
ents. Why, then, should the Navy 
Occupational Task Analysis Pro- 
gram (NOTAP) offer anything new 
in personnel research? Many simi- 
lar programs were funded in recent 
years and yielded much useful data, 
but most of these research efforts 
concentrated on a specific matter, 
not on Navy occupations in general 
or on long-range planning. Because 
each research group operated sepa- 
rately there was little standardiza- 
tion in the work, so it was difficult to 
apply the methods and findings of 
one research project to another. 

Recognizing the need for compre- 
hensive occupational task analysis 
data which could be adapted to con- 
tinuing needs, the Bureau of Naval 
Personnel (BUPERS) established 
NOTAP to collect and analyze data 
on Navy occupations. Later NOTAP 
and the BUPERS Occupational 
Standards Department were com- 
bined under the Navy Occupational 
Development and Analysis Center 
(NODAC), which is now analyzing 
tasks to develop better personnel 
classification systems. Every Navy 
enlisted rating will be analyzed and 
a data bank developed for use by 
personnel program managers. 

On 4 Jan 1977 the Navy Surgeon 
General approved NODAC's re- 
quest to analyze Hospital Corps 
tasks. The hospital corpsman rat- 
ing, which comprises many people, 
specializations, and commitments, 
is one of the most complicated Navy 
enlisted ratings, and will become 
even more complex as advancing 
technology brings increasing de- 
mands for specialized skills. How 
can the Hospital Corps satisfy 
everyone, yet maintain general 
rating skills, support the operating 
forces, and remain ready for corn- 
Volume 68, April 1977 



bat? To answer this question, we 
need all the help we can get. 
NOTAP may provide that help. 

Will the results of NOTAP be 
worth the effort involved? Should 
we spend this much of our time and 
resources to learn more about what 
hospital corpsmen actually do on 
the job? The answer is yes — if the 
product of this research will permit 
us to interpret problems better and 
make informed changes. No lesser 
result should be acceptable. 

BUMED Notice 1223 of 18 Feb 
1977 outlines the Hospital Corps 
NOTAP project. Questions may be 
directed to LCDR E.M. Knodle 
(MSC), BUMED's NOTAP project 
officer, or to HMCM F. A. Burkhart, 
at Autovon 294-4682. 

CORPSMEN, DENTAL TECHS 
NOW IN CREO GROUP D 

Hospital corpsmen and dental 
technicians may find it easier to re- 
enlist or extend their enlistment 
now that their ratings are included 
in CREO (Career Reenlistment Ob- 
jectives) Group D. While Group D 
ratings are 100% manned and there 
are some reenlistment and exten- 



sion restrictions, these restrictions 
aren't as severe as those imposed 
on Group E ratings. 

HM and DT ratings were formerly 
in Group E, which comprises se- 
verely overmanned ratings whose 
members could not reenlist or 
extend their enlistment without 
approval from the Bureau of Naval 
Personnel (BUPERS). 

The CREO Program began in 
1972 with three objectives: 

• To place more personnel in un- 
dermanned ratings (CREO Groups 
A and B). 

• To reduce the number of person- 
nel in overmanned or filled ratings 
(Groups D and E). 

• To provide attractive career pat- 
terns more useful to the Navy. 

To carry out the objectives, 
BUPERS developed rating profiles 
which described the optimum distri- 
bution of personnel by pay grade 
and length of service. Current 
management efforts aim to move 
Group A, B, and D ratings into 
Group C, representing ideal person- 
nel balances. Details on the CREO 
program are in BUPERS Instruction 
133. 25C (Change 2). 



NAVY DENTAL TECHNICIANS 



April 2, 1948-1977 



It is with pleasure that congratulations and best wishes are extended 
to you on the occasion of the Twenty-ninth Anniversary of the Dental 
Technician Rating. 

On April 2, 1948 the dental technician rating came into being when 
1,600 hospital corpsman, who had been trained in dental assisting and 
technology, sewed on the rating badge of the now familiar caduceus with 
a superimposed "D." 

Since this beginning, your deeds of valor, devotion to duty and skill- 
ful and innovative accomplishments have contributed greatly to the high 
standards of dental care provided by the Navy Dental Corps. Further, 
during the past year a substantial increase in the amount of dental 
care provided has been realized, without an increase in personnel. 
This outstanding achievement can, in large measure, be attributed to 
your dedication to duty and strong support of the Navy Dental Corps' 
goal— af reducing dental disease. 



alf of all of us in the Navy Medical Department, 
Anniversary. 




"Well Done" and 



M 



W. ELLIOTT YJr. 
Rear Admiral /Bf, USN 
Assistant Ctpefl for Dentistry 
and Chief, (en/al Division 




W. P. ARENTZEN 
Vice Admiral, MC)~ 
Surgeon General 



19 



IUAVMED Newsmakers 



When Sherry Hogan, pregnant 
wife of Navy construction electrician 
John Hogan, began to have labor 
pains, she immediately boarded an 
aeromedical evacuation flight bound 
for NRMC Naples, Italy. But even 
that wasn't fast enough for Sherry's 
daughter, who was born in the air- 
craft 20 miles south of Naples. 
LCDR Gerald Ross (MC) and LT 
Barbara Brake (NC) handled the 
mid-air delivery, with the aid of the 
flight attendant HM1 Joseph Wool- 
dridge. 

As leading petty officer in the 
USS Kalamazoo medical depart- 
ment, HM2 Robert W. Johnson is 
used to "putting out fires" when 
medical problems arise. But after 
his day aboard the, Kalamazoo ends, 
the energetic corpsman quickly 
changes his clothes and goes to 
fight real fires — with the Jackson- 
ville, Fla., fire department. A vol- 
unteer firefighter when his ship is 
in port, HM2 Johnson uses his six 
years of Navy medical experience 
in treating smoke inhalation and in- 
juries. 



Some people jog. Others do calis- 
thenics. But HM3 Maurice Orange 
of NRMC San Diego prefers a more 
exotic method of keeping in shape — 
Tae Kwon Do, a Korean style of ka- 
rate. In just four months the young 
corpsman became so proficient he 
finished first in the lightweight 
division at a local competition. His 
goals: to attain black belt status and 
to win a spot on the military team 
that competes in the Olympics. 

They faced each other, right 
hands raised, he repeating the 
words she spoke. Then he signed on 
the dotted line, and she did the 
same. "Congratulations, Chief hus- 
band, " she said. "Thank you, Lieu- 
tenant wife," he replied. Senior 
Chief Electrician's Mate Juan Victor 
Ruiz had just reenlisted in the Navy 
for four years, while his wife, LT 
CeferinaP. Ruiz (MC), officiated. A 
physician assigned to the branch 
clinic, Naval Training Center, San 
Diego, LT Ruiz met her future hus- 
band when both were second- 
graders in the Philippines, and 
joined him in the Navy in 1975. 





HMCS DuFrain with Drs. Hilton (left) 
and Morgan 



HM2 Johnson: Ready when problems arise 



20 



HMCS Larry DuFrain was tops in 
Navy medical recruiting during 
FY76, bringing on board seven new 
Navy physicians and five nurses. 
Since reporting to Navy Recruiting 
District, Denver, two and a half 
years ago, he has recruited 18 phy- 
sicians and many other Medical 
Department personnel. Two recent 
discoveries: Saskia C. Hilton, M.D., 
a pediatric radiologist who will be 
stationed with her Navy physician 
husband at NRMC San Diego; and 
Candice A. Morgan, M.D., a profi- 
cient scuba diver and pilot, who will 
train in aerospace medicine. 

Language proved no barrier when 
three Navy nurses from the branch 
clinic at Sasebo, Japan, met with 
local colleagues to discuss rehabili- 
tating the handicapped. Dr. Naoya 
Hara served as interpreter while 
escorting CDR Alyce M. Hines and 
LTs Ann Steffans and Christine 
Hoyle through National East Saga 
Hospital. Among the problems com- 
mon to the U.S. and Japan dis- 
cussed during the nurses' visit was 
the need for greater public accept- 
ance of handicapped people. 

U.S. Navy Medicine 



Professional 



A Custom Staining Technique for 
Natural-Looking Ceramic Restorations 



LT Paul E. Schmid, DC, USNR 



In modern dental restorative procedures, the em- 
phasis is on aesthetics. Unacceptable aesthetics 
translates directly into failure of the prosthesis, be- 
cause today's patients insist that their prostheses 
look natural. While proper fit, contour and occlusion 
are certainly vital components of a permanently suc- 
cessful prosthesis, the patient's immediate concern 
is the appearance of the restoration. 

Making a veneer simulate the appearance, charac- 
teristics, texture and color of a tooth can be difficult, 
and perfectly matching a patient's natural teeth may 
be impossible. For example, in a study of shade 
matching, Culpepper (1) found that because critical 
color perception varies from one individual to 
another, dentists often disagree when selecting a 
match for natural tooth shades. In fact, of the 37 
dentists who participated in Culpepper's study, no 
more than 39% agreed on any single match for 
natural teeth when selecting colors from a shade 
guide. Some dentists were not able to reliably dupli- 
cate their shade selections from one time to another. 
Thus, even when the dentist has taken great care in 
selecting and applying the proper body shade of por- 
celain, once viewed in the patient's mouth the resto- 
ration may need further laboratory attention to be 
aesthetically acceptable. 

In staining, today's ceramic technology gives us a 
tool which can make the difference between a medio- 
cre and a gratifying aesthetic result. Stains can be 
used to correct an improperly selected basic shade, 
to match a tooth for which there is no accurate shade 
guide, to reproduce special tooth characteristics, to 
adjust the blend on incisal areas, to mask out dirt 



LT Schmid is on the staff of the Dental Department, USS 
Shenandoah (AD-26), FPO New York 09501. 



Volume 68, April 1977 



and bright spots, and to control excess translucency. 
While there is no substitute for correct basic gingival 
and incisal colors in ceramic prostheses, stains can 
be used to increase the saturation of a color or to 
change the hue. But there are limits to what staining 
can do: it is difficult, if not impossible, to decrease 
the saturation of the color or increase the lightness of 
a porcelain crown or facing (2) . 

A true mineral stain affects the outer layer of por- 
celain. These surface stains are not widely used be- 
cause they are soon worn away in areas exposed to 
excessive wear or attrition (3) . More universally used 
are stains composed of colored, low-fusing porcelain. 
The stain is used in finely powdered form. This 
powder is suspended in water, glycerin and water, or 
a similar liquid which completely volatilizes during 
firing {4). Colored metallic oxides are added for pig- 
ment. Specific colors such as white are created with 
oxides of zirconia, and in some cases with oxides of 
alumina and silica. Yellows are made with pigments 
that contain vanadium, or from titanium oxide com- 
bined with a little chromium. Pink is difficult to 
produce because of the high firing temperatures re- 
quired, but colloidal gold may be used in its place. 
Black comes from modified iron oxide, and blue from 
cobalt salts {2). 

Generally, when self-glazing ceramics are used for 
a veneer or jacket crown, stains may be applied be- 
fore the final firing— or at the biscuit bake if the 
stains have a fusion point close to the glazing tem- 
perature of the porcelain (2). For example, when 
Steele's Super Stain (fusing temperature 1762° F.) is 
used on a Ceramco porcelain (self-glazing at approx- 
imately 1800° F.) the stain will fuse and melt into the 
porcelain; in this case an overglaze layer is rarely re- 
quired, but can be used to obtain an illusion of depth 
(2). 

21 



If a non-self-glazing porcelain is used, or if stains 
are applied to a previously glazed surface, or if the 
fusing point of the stain is not close to the glazing 
temperature of the porcelain, then an overglaze layer 
must be applied after the stain layer has been fired. 
This overglaze protects the newly applied stain and 
produces an even, glossy sheen on the surface of the 
restoration, consistent with natural aesthetics. 
Stains are applied by mixing pigmented porcelain 
powder with the liquid medium and painting this 
mixture on the restoration with a fine red sable 
brush. If the desired effect is not created, the stain 
can simply be wiped off and staining begun again 
(5). 

PRINCIPLES OF COLOR 

Color has three fundamental attributes: hue, 
brightness, and saturation. Hue, or basic color, is 
the quality of sensation through which an observer is 
aware that one color is green and another is red. 
Brightness, or value, indicates the amount of light 
reflected from a surface, and is the quality that en- 
ables us to distinguish a light color from a dark one. 

The extremes of brightness are black (0 on the 
value scale) and white (100 on the value scale), while 
gray represents intermediate brightness. The bright- 
ness of a color is determined by which gray on the 
value scale it matches in lightness or darkness. 
Every porcelain shade has a numerical value on the 
brightness scale; Ceramco white modifier, for exam- 
ple, has a value of 71, and Ceramco gray modifier 
has a brightness of 39, with the remaining body 
shades falling between these two values. Any at- 
tempt to darken a tooth shade by adding gray will not 
succeed if the added gray is higher on the brightness 
scale than the original shade. For example, if the 
color to be darkened has a brightness value below 
that of medium gray, and a gray brighter than 
medium is added, the result will be increased bril- 
lance: the tooth shade will lighten rather than darken 
(6). 

The third attribute of color— saturation, or chroma 
—is that property which makes one sample of a hue 
appear more intense or pure than a second sample. 
Chroma describes the amount of hue in a color and is 
the quality which distinguishes a strong color from a 
weak one. 

Hue, brightness, and saturation may be used to 
describe completely the color of any object. For ex- 
ample, the incisal edge of a tooth may lack bright- 
ness and be gray in color. But toward the gingival 
third of the tooth the enamel becomes thinner and 
light is reflected from the basically yellow dentin 



Orange 




Yellow 



Green 

FIGURE 1. Color wheel. 

core; here the hue changes to yellow, becoming 
progressively more saturated (7). 

The primary colors red, yellow, and blue can be 
blended to create the secondary colors green, violet 
and orange, as illustrated in the color wheel in 
Figure 1 . The color directly opposite another on the 
wheel is called a complementary color. 

Because the basic hue of a tooth is yellow, the 
color can deviate in only three ways: in hue, by being 
a reddish-yellow (orange) or a greenish-yellow; in 
brightness, by reflecting more or less light than a 
medium gray; and in saturation, by being a stronger 
or weaker yellow (7). Staining adds color, neutralizes 
excessive color, or reduces brightness when porce- 
lain has too much white and is too bright (S). 
. Color can be added in several ways: For example, 
if the nearest shade of porcelain powder that can be 
found to match a natural tooth is too orange because 
it contains too much red, the hue can be changed by 
adding a slightly brighter, yellow-green porcelain 
stain; the green cancels the effect of red and 
produces a gray color (7). The addition of gray to the 
incisal shade can turn the darker yellow shades 
green, since gray acts on yellow in the same way 
blue acts on yellow to form green. But the addition of 
violet will neutralize the yellow and yield gray, with 
less of the greenish effect that can ruin a natural ap- 
pearance. 

Occasionally, too much color is built into the por- 
celain. Blending complementary colors has a neu- 
tralizing effect: if complementary hues of unequal 
chroma or saturation are blended, the dominant 
color's brightness is diminished and the color be- 
comes grayer. If complementary hues of equal 
chroma and value are blended, a neutral gray is 
created (6"). 



22 



U.S. Navy Medicine 



Gray should be added to reduce brightness when 
little yellow is present. If a shade with prominent 
yellow must be darkened, the overlay should be 
brown to avoid a greenish tinge. To decrease the 
saturation of color, a more saturated modifier of the 
same hue and brightness should be added. 

In addition to changing color, various stains can be 
used to individualize restorations and to reproduce 
on a porcelain restoration the distinctive characteris- 
tics of the natural tooth. First, a color distribution 
chart of the natural tooth's labial surface should be 
drawn to exact anatomic form and divided into thirds 
incisocervically and mesiodistally (Figure 2). This 
chart will assist in locating and appraising the ir- 
regular border where the gingival color overlaps the 
mesial and distal surfaces and blends with the incisal 
shade. Areas of incisal translucence can be identified 
on the chart, as can calcified areas, hairline cracks 
and stains. The chart should list every surface char- 
acteristic and irregularity that must be reproduced in 
the restoration to achieve an aesthetically pleasing, 
harmonious result (7). Using the chart as a place- 
ment guide, stains can be used to simulate the fol- 
lowing: 

• Hairline crack, simulated by applying brown stain 
mixed with a little black stain. The mixture is applied 
first in a wide strip on the labial surface; then, with a 
fine pointed brush, the sides of the line are gradually 
brushed away until only a very fine, not always con- 
tinuous line remains. 

• Incisal wear, simulated by selective grinding in 
the central area of the incisal edge of the crown to 
duplicate wear, and staining the area with a mixture 
of one part yellow, one part brown, and two parts 
diluent. The center of the stained area may be un- 
diluted brown, simulating the exposed and more 
heavily stained dentin. 

• Cervical stain, made by reproducing any surface 



Incisal Shade 



Character ' 
izations 




2 Gingival + 
1 Incisal 
|Blended] 



Gingival Body 
Shade 



FIGURE 2. Color distribution of natural tooth's labial surface. 



or contour changes in the porcelain which may have 
been made by recession or abrasion, then by staining 
such areas with a mixture of three parts brown, one 
part yellow and four parts diluent. Areas of darker 
brown can be reproduced by placing small dots of 
brown stain on the wet surface and feathering the 
edges with a fine brush. 

• Decalcified areas, made by forming a small ir- 
regular depression in the porcelain. A thick layer of 
opaque white stain, alone or with a trace of yellow, 
brown, or gray, is poured into the depression (2). 

• Grooves and pits on an occlusal surface. Fine lines 
of brown stain with a small quantity of black are ap- 
plied to the occlusal surface. 

• Silicate restoration. A line of brown or gray stain, 
representing the outline of the restoration, is first 
painted on the labial line angle. This line is narrowed 
and the portion inside the line is covered with 
opaque white mixed with gray, yellow, brown, or a 
combination of these three colors. 

• Amalgam restoration. A line of gray stain is placed 
on the proximal line angle and feathered over 2 mm 
to give the appearance of the stain that results from 
an alloy restoration {2). 

The creation of natural-appearing porcelain ve- 
neers is an art which can be mastered only with a 
thorough understanding of colors and their modifica- 
tion, and with practical experience in the laboratory. 
Proficiency in staining may be obtained by sand- 
blasting a porcelain denture tooth and practicing dif- 
ferent modifications. One should always strive to 
build the proper shade and value into the veneer in 
its fabrication; however, the custom touch that stain- 
ing can add to create a natural-appearing restoration 
will be a source of pride to patient and dentist alike. 

REFERENCES 

1. Culpepper WD: A comparative study of shade matching 
procedures. J Prosthet Dent 24(2):173, 1970. 

2. Johnston JF, Mumford G, Dykema RW: Modern Practice 
in Dental Ceramics. Philadelphia: W.B. Saunders Co, 1967. 

3. Tylman S: Theory and Practice of Crown and Fixed Partial 
Prosthodontics (Bridge). St. Louis: C.V. Mosby Co, 1970. 

4. Skinner EW, Phillips RW: The Science of Dental Materi- 
als. Philadelphia: W.B. Saunders Co, 1976. 

5. Richardson JT, Gardner MF: Contouring and staining 
ceramic-metal restorations in the mouth. J Prosthet Dent 
33(6):639, 1975. 

6. Kornfeld M: Mouth Rehabilitation: Clinical and Laboratory 
Procedures. St. Louis: C.V. Mosby Co, 1974. 

7. Johnston JF, Phillips RW, Dykema RW: Modern Practice 
in Crown and Bridge Prosthodontics. Philadelphia: W.B. 
Saunders Co, 1971. 

8. Granger RG: Dynamic esthetics in porcelain-veneered 
fixed prostheses. J Prosthet Dent 32<5):541-542, 1974. 



Volume 68, April 1977 



23 



Clinicopathological Study 
of Aortic Valve Replacement 



ENS Felipe C. Robinson, USNR 



Management of far-advanced aortic valve disease 
has progressed considerably since Harken and his 
colleagues introduced the ball-valve prosthesis in 
1960 (J). Many new valves have been developed 
using both artificial and biological materials. Al- 
though the designs of the valves vary, they generally 
conform to the criteria Harken {2) outlined for an 
optimal prosthetic heart valve: 

• lasting physical and geometric features. 

• capability of permanent implantation in the nor- 
mal anatomic valve site. 

• chemically inert. 

• non-thrombogenic. 

• harmless to blood elements. 

• adequate opening and closing during the appropri- 
ate phase of the cardiac cycle. 

• offering no resistance to physiologic flow. 
Although no single approach has been satisfactory 

in all situations (5), over the past 10 years the Starr- 
Edwards series 2300 cloth-covered aortic valve has 
been by far the most commonly used prosthesis for 
treating aortic valve disease. 

This valve has been the most commonly used 
aortic prosthesis at the University of Florida College 
of Medicine in Gainesville (Figure 1), where from 
1969 to 1975, in the J. Hillis Miller Health Center, 
223 patients have undergone aortic valve replace- 
ment with the composite-seat, cloth-covered, Model 
2310 and 2320 Starr-Edwards aortic valve prosthesis 
(3M-Starr Edwards). Because late complications 
have been attributed to this prosthesis, 10 randomly 
selected surgical pathology and postmortem records, 
as well as associated clinical records, were analyzed 
for evidence of mechanical or biogenic disruption. 
The purpose of this study was to determine the effec- 
tiveness and durability of the valves, and to compare 
the results of this analysis with other studies of 
prosthetic aortic valve efficacy. 

ENS Robinson is a medical student at the University of Florida 
in Gainesville. His address is: Box J-719, J. Hillis Miller Health 
Center, Gainesville, Fla. 32610. 

The author thanks George Daicoff, M.D., chief of thoracic and 
cardiovascular surgery at the University of Florida College of 
Medicine, for guidance during this study and for assistance in 
preparing this report. 



METHOD 

Surgical pathology and postmortem records and 
associated clinical records of ten randomly selected 
patients were analyzed. Nine of these ten patients 
had died at least two months after their aortic valve 
was replaced. One patient was selected from a group 
who survived replacement of a dysfunctional Starr- 
Edwards valve. The age and sex of the patients and 
the site of replaced valves are shown in Table I. All 
patients were in functional classes III or IV of the 
New York Heart Association classification before 
their operation. All patients were male. Ages ranged 
from 29 to 70 years (average 49 years). 

Table II shows the preoperative valvular lesions, 
etiology of the lesions, and for the nine deceased 
patients, the cause of death. The etiology of the 
valvular lesions varied. Four patients had diagnosed 



AORTIC PROSTHESES 




HANCOCK 
STARR -EDWARDS 



BJ0RK-SHILEY 



62 63 64 65 66 67 6S 69 70 71 72 73 74 75 
YEAR 

FIGURE 1. Prosthetic valves implanted at the University of 
Florida College of Medicine between 1962 and 1975. 



24 



U.S. Navy Medicine 



aortic insufficiency and aortic stenosis secondary to 
rheumatic heart disease. Two patients had preopera- 
tive diagnoses of aortic insufficiency and aortic 
stenosis secondary to bacterial endocarditis; another 
two had a congenitally malformed bicuspid aortic 
valve. One patient had aortic stenosis secondary to 
atherosclerosis. The tenth patient had syphilis. 

In replacing the valves, standard techniques of 
cardiopulmonary bypass had been used, with a roller 
pump, bubble or disc oxygenator, and moderate 
whole body hypothermia (30° C). Topical 4° C iced 

TABLE I. Identification and Survival Time of Patients 
with Starr-Edwards Series 2300 Prosthetic Aortic Valve 



Specimen 


Size 


Model No. 


Sex 


Race 


Age 


In vivo duration 


N.C. 


9A 


2320 


M 


W 


53 


5 


J.F. 


9A 


2320 


M 


W 


29 


15« 


B.E. 


10A 


2320 


M 


W 


63 


24 


T.S. 


10A 


2320 


M 


B 


48 


19 


J.M.F. 


9A 


2320 


M 


W 


36 


8 


J.M. 


10A 


2320 


M 


W 


62 


48 


G.R. 


9A 


2320 


M 


w 


70 


28 


J.C. 


10A 


2320 


M 


w 


44 


25 


J.N.C. 


12A 


2310 


M 


B 


65 


3 


O.T. 


13A 


2320 


M 


B 


33 


24 



f Valve replaced by Hancock valve 



saline lavage was also used in some patients to 
protect the myocardium. Aortic defibrillation and 
cross-clamping were sometimes used. Standard 
doses of sodium warfarin or a combination of acetyl- 
salicylic acid and dipyridamole were given to prevent 
postoperative thromboembolism. 

ILLUSTRATIVE REPORTS 

Patient 1. J.F., a 29-year-old white male who is an inmate in 
a correctional institute, had a six-year history of progressive 
shortness of breath, dyspnea on exertion, and insidious increase 
in heart size. There was no history of rheumatic heart disease. 
Cardiac catheterization in June 1973 revealed substantial aortic 
insufficiency and aortic stenosis, and the patient was assessed to 
be in functional class in of the N.Y. Heart Association classifica- 
tion. At surgery one month later, a heavily calcified bicuspid 
aortic valve with an approximately 6 mm orifice was found. The 
aortic valve was replaced with a size 9A, fabric-covered Starr- 
Edwards prosthesis in an operation that required 93 minutes of 
cardiopulmonary bypass. The patient tolerated the procedure 
well. His hospital course was unremarkable and he was 
discharged seven days after surgery. 

At six weeks after surgery, the patient was asymptomatic (Fig- 
ure 2). At the end of his first postoperative year, he complained of 
"weakness" and shortness of breath. Cardiac catheterization 14 
months after surgery revealed significant residual aortic stenosis; 
laboratory studies before catheterization revealed a hematocrit of 
25% and a reticulocyte count of 5.1% (corrected), suggesting 
hemolytic anemia and dysfunction of the prosthetic valve. 



TABLE II. Diagnosis, Etiology of Disease, 
Death of Patients in Study 


and Cause of 


Patient 


Pre-surgery diagnosis 


Etiology 


Cause of death 


N.C. 


Aortic insufficiency and 
aortic stenosis 


Secondary 
to bacterial 
endocarditis 


Secondary 
to bacterial 
endocarditis 


J.F. 


Aortic insufficiency and 
aortic stenosis 


Congenital 
malformation 


Surviving 
patient 


B.E, 


Aortic insufficiency and 
aortic stenosis 


Secondary 
to bacterial 
endocarditis 


Iatrogenic 

aortic 

laceration 


T.S. 


Aortic insufficiency and 
aortic stenosis 


Rheumatic 
heart disease 


Intraoperative 
demise during 
replacement 
of prosthesis 


J.M.F. 


Aortic insufficiency and 
aortic stenosis 


Rheumatic 
heart disease 


Sepsis 


J.M. 


Aortic stenosis 


Atherosclerosis 


Interstitial 
pneumonitis 


G.R. 


Aortic insufficiency and 
aortic stenosis 


Congenital 

malformation 


Cardiovascular 
arrest 


J.C. 


Myocardial insufficiency, 
aortic insufficiency and 
aortic stenosis 


Rheumatic 
heart disease 


Cardiogenic 
shock 


J.N.C. 


Aortic stenosis 


Syphilis 


Mycotic sepsis 


O.T. 


Aortic insufficiency and 
aortic stenosis 


Rheumatic 
heart disease 


Myocardial 
infarction 




FIGURE 2. Prosthetic valve is seen in situ in this photograph 
of a lateral chest X-ray taken six weeks postoperatively. 



Volume 68, April 1977 



25 



At subsequent surgery, the fabric on the struts of the valve was 
found to be ruptured and significant amounts of pannus had 
formed around the orifice of the valve, creating a stenotic outflow 
tract. The valve was removed (Figure 3) and replaced by a Han- 
cock porcine heterograft. The patient's postoperative course was 
complicated by development of heart failure and a murmur asso- 
ciated with mitral insufficiency; it was postulated that the mitral 
valve may have been disrupted by efforts to remove fibrous tissue 
and pannus from around the aortic annulus near the mitral and 
aortic continuity. Cardiac catheterization confirmed the presence 
of postoperative iatrogenic mitral insufficiency. 

The incision was reopened and a laceration of the mitral valve 
was sutured. The patient tolerated the procedure well; his post- 
operative course was uneventful and he was discharged in satis- 
factory condition. 

The patient has been followed in the outpatient clinic and has 
been asymptomatic throughout the 2Va years since his surgery. 
Chest roentgenogram has demonstrated a remarkable reduction 
in heart size toward normal limits. The only sequela is right 
bundle branch block demonstrated on electrocardiogram. Cardiac 
auscultation revealed a grade 11/ VI systolic murmur of blowing 
character radiating from the apex to the left axilla, indicating 
some mild residual mitral insufficiency. 

Patient 2. N.C. was a 53-year-old white male who was trans- 
ferred from another hospital to the Shands Teaching Hospital at 
the J. Hillis Miller Health Center on 22 Oct 1971 with the 
diagnosis of subacute bacterial endocarditis. The patient had had 
a heart murmur since childhood with no known rheumatic heart 
disease or febrile illness. He was asymptomatic until 1962 when 
he developed shortness of breath, dyspnea and paroxysmal 
nocturnal dyspnea. In early 1971, the patient experienced anginal 
pain, dyspnea and easy fatigability. On 16 June 1971, the patient 
underwent cardiac surgery in which his calcific, stenotic aortic 
valve was replaced by a Starr-Edwards valve. Successful reex- 
ploration was done the same day for excessive bleeding. The 




patient did well postoperatively. He was placed on digoxin and 

Coumadin therapy, and discharged. He returned to work in late 
August 1971. 

Three weeks before his present admission, he had some dental 
work done and soon thereafter complained of headache and chills 
in the afternoon, with temperature of 101-102° F. The patient's 
physician drew blood for culture and started him on penicillin. On 
4 Oct 1971 the patient had painful swelling of his left hand and 
right foot, and a blind spot in his left eye. He was hospitalized in 
St. Petersburg where two of three blood cultures grew diphthe- 
roids. The patient was treated with various antibiotics and pred- 
nisone, and transferred to Shands Teaching Hospital. 

Cardiac examination on admission to Shands Teaching Hos- 
pital revealed a short systolic murmur in addition to the valve 
murmur. Laboratory studies disclosed the following values: 
WBC, 20,300/cu mm; hematocrit, 45%; lactic dehydrogenase 
(LDH), 200; electrolytes within normal limits. The patient was 
started on Keflin with a subsequent drop in temperature and 
white blood count. Electrocardiogram showed signs of an old 
anterior myocardial infarct. The patient was afebrile until 4 Nov 
1971; blood cultures grew no organisms. 

Intermittent fever was noted on 4 November. The white blood 
count of 6,600/cu mm gradually increased. A sore left thumb and 
right calf were interpreted as signs of recurrent septic embolism. 
Keflin was stopped since it did not seem to control the infection, 
and more blood cultures were obtained, On 16 November, with 
the patient's status unchanged, a mycotic aneurysm of the right 
foot was excised and sent for culture. At midnight on 16 
November, the patient developed acute tachycardia, diaphoresis, 
and shortness of breath with bilateral pulmonary edema. The pa- 
tient's blood pressure measured 75mm/mercury systolic; the 
murmur was unchanged. Mild hemoptysis developed on 17 
November. Subsequent catheterization ruled out pulmonary 
embolism or significant aortic regurgitation. After catheteriza- 
tion, the patient was obtunded. Resuscitation measures failed 
after two hours, and the patient was pronounced dead at 1650 on 
17 Nov 1971. 



FIGURE 3. This Starr-Edwards prosthetic aortic valve was 
removed from a patient 15 months after it was implanted. 
Note the torn strut covering on two of the three sides. 



RESULTS 

No apparent correlation was found between the 
etiology of the valvular lesion and how long the pa- 
tients lived or how long their valves remained func- 
tional. Nor was there apparent correlation between 
length of survival and mortality due to valve dysfunc- 
tion. 

Table III shows pertinent clinical data and 
describes the valve's condition in each case. Clinical 
data includes the maximum immediate preoperative 
serum lactate dehydrogenase (LDH) level, minimum 
preoperative hematocrit, and maximum preoperative 
reticulocyte count. Where available, results of blood 
cultures and serum haptoglobin concentration levels 
are also shown. 

Maximum LDH levels ranged from 276 to 757 
units (mean 393.7 units) in patients whose valves 
demonstrated signs of wear or dysfunction; LDH 
levels for patients with intact valves ranged from 258 
to 511 units (mean 356.3 units). Minimum hemato- 



26 



U.S. Navy Medicine 



TABLE III. Clinical data and valve description. 



Preoperative Clinical Data 
Min. Max. Max. 

Hct RetC. LDH 



Valve Description 



N.C. 


30 — 276 




Blood cufture grew Diph- 




theroids 


J.F. 


25 5. 1 


B. FL 


28 2. 5 m 


J.C. 


28 - 



Blood culture grew Candida 
Guilliermoni 



J.N.C. 34 



O.T. 



Haptoglobin 10 mg. * 



Friable adhesions on all sides 
of annulus and struts with 
insufficient seating of ball. 

Annulus stenosed by fibrosis. 
Small amounts of fibromuscu- 
lar tissue adherent to annu- 
lar base. Cloth rupture evi- 
dent on struts. 

Paravalvular leak noted. Strut 
covering torn on two out of three 
sides. Annular flanges denuded. 

Valve covered with finely granular 
vegetative growth on both sides 



No ball variance or strut 
wear noted. No evidence of 
librotic stenosis of annulus. 

Cloth rupture on two out 
of three struts- Aortic root 
gralt in place. No apparent 
wear of orifice or ball vari- 
ance. 



r. s. 


30 


"~ 


330 


Strut covering torn on all three 
sides. Orifice flanges denuded. 
No evidence of ball variance. 


J.M.F. 


23 


3.3 


757 


Fibrotic stenosis and calcification 
of annulus noted with exposure 
o( annular flanges. 


J.M. 


38 


— 


450 


Calcified annulus. No ball vari- 
ance or strut wear noted 


G.R. 


32 


— 


258 


No evidence of ball variance or 
strut wear. Difluse interstitial 
fibrosis noted in left ventricular 
myocardium. 




FIGURE 4. Autopsy specimen shows thrombotic material at 
annulus of valve preventing ball from seating properly. The 
struts of the prosthesis are also covered by friable fibrinoid 
material. 



crit values for patients with dysfunctional valves 
ranged from 23% to 38% (mean 29%, standard de- 
viation 5.215), while hematocrits for patients with 
intact valves ranged from 28 % to 34 % (mean 31 .3 % , 
standard deviation 3.05). 

Three of the ten valves showed no signs of signifi- 
cant wear. Seven of the ten valves showed signs of 
dysfunction ranging from moderate fibrotic stenosis 
of the annulus to obvious ruptures in the knotted 
fabric on the struts, with a denuded metal flange in 
the annulus of the valve (Figure 4). 

On comparing patients' survival time to valve 
wear characteristics and clinical data, we found a 
mean survival time of 20 months for dysfunctional 
valves compared to 19 months for nondisrupted 
valves; this difference in survival time is not statisti- 
cally significant. 

No deaths were unequivocally attributed to valve 
dysfunction. The most clear-cut demonstration of 
morbidity related to valve dysfunction is reported in 
the case of the lone surviving patient (Patient 1). 

DISCUSSION 

Use of caged-ball prosthetic aortic valves dates 
back to 1954, when Hufnagel (4) first treated aortic 
regurgitation with a valve of his own design. The 
Hufnagel prosthesis was a lucite ball in a solid 
cylindrical lucite cage; the prosthesis was designed 
to be rapidly inserted in the descending aorta and 
held in place by fixation rings. Several complications 
were observed, including a high incidence of 
peripheral embolization, frank thrombosis of the 
entire valve, and infection. Over the next 10 years, 
Harken (i) and others developed flexible valve leaf- 
lets to implant within the heart. When the strength 
of these materials quickly became a critical factor, 
Harken (2) and Starr (5) began work to develop a 
rigid prosthetic valve based, ironically, on the caged- 
ball principle. Starr performed the first clinically 
successful implantation of the new valve in 1960 (5) . 
Thrombogenicity continued to be a major problem 
of implanting the early valves. Since the prosthetic 
valve is a foreign object in the bloodstream, protein 
is adsorbed onto its surface and platelets are stimu- 
lated to adhere and aggregate, encouraging throm- 
bosis and embolization. Attempts to reduce throm- 
bogenicity led to Braunwald and Boncheck's dis- 
covery that tissue ingrowth on porous, fabric- 
covered prostheses minimized thrombus formation 
(6). The logical extension of this discovery was to 
cover the cage with porous fabric, from which came 
the cloth-covered 2300 series Starr-Edwards aortic 



Volume 68, April 1977 



27 



valves, later replaced by the 2310 and 2320 series. 

Complications associated with the 2300 series of 
valves included unsatisfactory postoperative valve 
gradients (7) and excessive tissue ingrowth which 
further compromised the function of the valve (8). 
The 2310 series valves reportedly caused a lower rate 
of embolism but showed increased fabric wear on the 
struts (9). Also, reduced clearance between ball and 
struts, a design improvement intended to increase 
the durability of cloth around the orifice of the an- 
nulus, predisposed these valves to problems of ball 
sticking (3). Design modifications for the newer 2320 
aortic valves have reduced thrombogenicity and in- 
creased the valve's durability. 

Hodam and his associates (10) in their review of 
120 patients with isolated aortic valve replacement 
and 48 patients with multiple valve replacement with 
Starr-Edwards model 2310 aortic prostheses found 
elevated serum LDH levels, an index of hemolysis, in 
all patients; the mean hematocrit was 41.2% (stand- 
ard deviation, 3.05). These values are significantly 
higher than values we observed in patients with 
valve dysfunction during our study, but not statisti- 
cally different from the values we obtained in pa- 
tients without significant dysfunction. We did not 
see the "stuck ball syndrome" reported by Hodam 
in any of our patients. 

In a nine-year review of 1,022 patients whose 
aortic valve was replaced with a Starr-Edwards pros- 
thesis, Banhorst and his associates (11) observed an 
80 % probability of survival in patients who survived 
the first 30 days after the model 2310 prosthesis was 
substituted for the aortic valve. In addition, they 
predicted these probabilities of five-year survival 
based on the dominant aortic lesion: aortic stenosis 
and aortic insufficiency, 70%; aortic stenosis only, 
80%; aortic insufficiency only, 82%. These survival 
rates are much higher than the 20-month mean sur- 
vival time we observed in our patients. 

In assessing late demise among 957 patients, 
Banhorst found these to be the principal causes of 
death: sudden unexpected death (25%), coronary 
disease (17%), thromboembolism (15%), congestive 
heart failure (9%), and bacterial endocarditis (8%). 
Valve failure accounted for 7% of the deaths 
(thrombus 3%, dehiscence 3%, and ball variance 
1 %). These rates are not significantly different from 
our observations. 

In a six-year appraisal of late complications 
following aortic replacement of the valve with cloth- 
covered, composite-seat model 2310 and 2320 
prostheses, Starr and his associates (12) followed 116 
patients who were anticoagulated with warfarin post- 



operatively and 134 patients who were not anticoagu- 
lated postoperatively. The number of late deaths in 
the anticoagulated group was 14%, compared to 
16% in the group that was not anticoagulated. The 
causes of death did not differ significantly between 
the two groups, with congestive heart failure and 
coronary artery disease the principal causes. The 
main cause of prosthesis-related death in both 
groups was bacterial endocarditis. These findings 
are similar to our observations, but the survival time 
reported is considerably longer than we observed. 
However, since Starr's study included 46% Class I 
and 41% Class II patients, and only 12% Class III 
and 1% Class IV patients, the difference in survival 
times may be explained on the basis of higher selec- 
tivity. 

CONCLUSION 

Starr-Edwards series 2300 aortic valves have clear 
design limitations. The ultimate goal of aortic valve 
replacement is to improve the patient's clinical con- 
dition and to avoid postoperative complications. A 
continued effort to improve prostheses and develop 
superior new designs and materials is warranted. 

REFERENCES 

1. Harken DE, et al: Partial and complete prostheses in aortic 
insufficiency. J Thorac Cardiovasc Surg 40:744, 1960. 

2. Harken DE, et al: Aortic valve replacement with a caged- 
ball valve. Am J Cardiol 9:292, 1962. 

3. Roberts WC, et al: Pathologic anatomy of cardiac valve re- 
placement: A study of 224 necropsy patients. Prog Cardiovasc 
Dis 15:539, 1973. 

4. Hufnagel CA, et al: Surgical correction of aortic insuffi- 
ciency. Surgery 35:673, 1954. 

5. Starr A, Edwards ML: Mitral replacement: Clinical experi- 
ence with a ball-valve prosthesis. Ann Surg 154:776, 1961, 

6. Braunwald NS, Boncheck LI: Prevention of thrombus for- 
mation on rigid prosthetic heart valves by the ingrowth of 
autogenous tissue. J Thorac Cardiovasc Surg 54:630, 1967. 

7. Bristow JD, et al: Clinical and hemodynamic observations 
after combined aortic and mitral replacement. Circulation 31-32 
(suppl 1):67, 1965. 

8. Winter TO, et al: Current status of Starr-Edwards cloth- 
covered prosthetic cardiac valves. Circulation 33-34(suppl 2):69, 
1971. 

9. Boruchow IB, et al: Complications following destruction of 
the cloth covering of a Starr-Edwards aortic valve prosthesis. J 
Thorac Cardiovasc Surg 62:290, 1971. 

10. Hodam R, et al: Further evaluation of the composite seat 
cloth-covered aortic prosthesis. Ann Thorac Surg 12:621, 1971. 

11. Banhorst DA, et al: Isolated replacement of the aortic 
valve with the Starr-Edwards prosthesis. J Thorac Cardiovasc 
Surg 70:113, 1975. 

12. Starr A, et al: Late complications of aortic valve 
replacement with cloth-covered composite-seat prostheses. Ann 
Thorac Surg 19-289, 1975. 



28 



U.S. Navy Medicine 



Letters 



SURGERY AT SEA 

Medical officers at sea don 't have 
the facilities to perform major sur- 
gery — so thought LCDR Danny V. 
Cantwell (MC), a general surgeon, 
when he began his tour aboard the 
USS John F. Kennedy in July 1976. 
But things are seldom what they 
seem, as LCDR Cantwell reports. 
[Ed.] 

Expecting a dearth of surgery and 
an excess of imaginary illness, I was 
pleasantly surprised to find myself 
embroiled in an appendectomy our 
first day at sea. Little did I suspect 
that we would do so much major 
surgery in just my first two months 
aboard. The physical facilities were 
remarkably complete and gave us 
the capability of salvaging severely 
injured patients. 

Surgery cannot take place without 
competent anesthesia, and the Ken- 
nedy was fortunate to have an oral 
surgeon and a flight surgeon to 
administer excellent general and 
regional anesthesia. Although the 
ship is not a regional medical cen- 
ter, imagination, drugs, instru- 
ments and suture made possible a 
remarkable array of surgical pro- 
cedures. Indeed all emergency and 
most elective procedures which 
could be accomplished with local or 
regional anesthesia were performed 
without complications. Postopera- 
tive care was adequate. Many men 
underwent herniorrhaphy or appen- 
dectomy with relatively rapid return 
to limited or full duty, and without 
the need for costly hospitalization or 
a long wait for shore-based care or 
convalescence. 

The true test of our surgical team 
came on 14 Sept 1976, the day of the 
collision with the USS Bordelon. 
Movement of patients from the 
Bordelon and prompt triage re- 
sulted in efficient treatment of a 
moderate number of casualties. 
Previously established blood donor 
procedures provided rapid availabil- 
ity of type-specific blood and en- 
abled us to save two lives. Resusci- 



tating and operating on a severely 
injured patient was not only possi- 
ble but surprisingly easy because of 
our prior preparation. The aeromed- 
ical evacuation system was found to 
be somewhat cumbersome. Most 
patients can and should be treated 
on the Kennedy until they are stable 
and a planned aeromedical evacua- 
tion can be arranged. The Ken- 
nedy's excellent medical facilities 
enabled us to render more sophisti- 
cated emergency care to the task 
force than is generally appreciated. 

LCDR D.V. Cantwell, MC, USNR 

Medical Department 

USS John F. Kennedy 

FPO New York 09501 

COLD MEDICATIONS 

I want to congratulate U.S. Navy 
Medicine and CDR Gorske for the 
article entitled "Let's Stop Pre- 
scribing Cold Medications" [US 
Nav Med 67(11):10-13, Nov 1976]. 

Thomas E. Frothingham, M.D. 

Professor of Pediatrics and 
Community Health Sciences 

Duke University Medical Center 

Durham, N.C. 27710 

PREMED ADVTCE 
FOR CORPSMEN 

During a recent active- duty-for- 
training period at Naval Regional 
Medical Center, Great Lakes, 111., I 
was assigned to the medical cen- 
ter's education and training office 
and spoke with many hospital corps- 
men who visited the office to ask 
about pre-medical courses offered 
in the evening at local colleges. It 
was evident that some of these 
corpsmen had unrealistic ideas 
about the qualifications needed to 
gain admission to medical school. 
While most of them recognized the 
importance of maintaining a high 
scholastic average, they did not 
know the exact grade point average 
attained by applicants who were 
successful in the past. Relatively 
few of the corpsmen realized that 
they must get acquainted with their 
evening school professors if they 
hoped to obtain meaningful recom- 
mendations from them. The format 
of the medical college admissions 



Volume 68, April 1977 



test, and procedures used to inter- 
view medical school applicants also 
were unfamiliar to these prospec- 
tive medical school applicants. 

These corpsmen were certainly 
well motivated to pursue careers as 
physicians. Their daily work indi- 
cated their concern for the well- 
being of others, and they had a real- 
istic view of a practicing physician's 
duties. But they were not aware that 
even as part-time students they 
were establishing their academic 
value. 

I suggest that a pre-med advisory 
council similar to the pre-med clubs 
on college campuses be established 
at NRMC Great Lakes and other 
regional medical centers. This coun- 
cil could be chaired by medical offi- 
cers who are recent medical school 
graduates and who recognize the 
problems of gaining admission to 
medical school. 

Information on admissions pro- 
cedures and requirements and on 
trends in medical education is avail- 
able from the Association of Ameri- 
can Medical Colleges, 1 Dupont 
Circle N.W., Washington, D.C. 
20036. This association publishes 
two useful journals — The Advisor 
and the Journal of Medical Educa- 
tion — a weekly newsletter, and the 
annual book, Medical School Ad- 
missions Requirements, all of which 
contain information about American 
and Canadian medical schools. 
Topics of interest to the medical 
school applicant are covered in the 
last issue each year of the Journal of 
the American Medical Association. 
Many regional medical centers 
are located near medical schools. 
Members of admissions committees 
and other faculty members at those 
schools could be asked to speak to a 
highly motivated group of hospital 
corpsmen. Such programs would be 
informative for future medical 
school applicants and would boost 
the morale of participating hospital 
corpsmen. 

CDR A.M. Earle, MSC, USNR 
Associate Professor of Anatomy 
The University of Nebraska 

Medical Center 
Omaha, Neb. 68105 



29 



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